Infection Prevention and Control Annual Report - Northumbria NHS ...

Infection Prevention and Control
Annual Report
2010 – 2011
Produced by:
Dr Bryan Marshall, Director of Infection Prevention and Control
6 June 2011
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Contents
Page
Executive summary 3
1. Introduction 4
2. Infection Control Arrangements
- Trust Board
- Infection Control Team
- Infection Control Committee
- Assurance Framework
3. Health and Social Care Act 2008 – Code of Practice for the Prevention 5
and Control of Healthcare Associated Infection
4. NHSLA standards 5
5. Annual programme 2010-11 6
6. Annual programme 2011-12 7
7. Service Improvement – MRSA improvement programme 7
8. Service Improvement – Clostridium difficile improvement programme 8
9. Service improvement – surgical site infection improvement programme 8
10. Outbreaks 9
11. Other surveillance programmes 9
12. Audit 10
13. Education and Training 11
14. Decontamination and cleanliness 12
15. Antibiotic stewardship 12
16. Patient and public involvement 12
17. North of Tyne HCAI group 12
18. Safer Care NE 12
19. The future 13
Appendix 1: Health and Social Care Act 2008 self assessment compliance 14
summary March 2011
Appendix 2: Health and Social Care Act 2008 outcome data March 2011 21
Appendix 3: Annual programme 2010-11 – progress report 27
Appendix 4: Annual programme for Acute services 2011-12 30
List of tables and charts
Figure Description Page
1 MRSA bacteraemias identified by Northumbria Healthcare NHS Foundation 7
Trust compared to target, for period April 2002 to March 2011.
2 Timing of specimen collection in relation to admission for MRSA bacteraemias 7
3 Number of newly diagnosed cases of C.difficile infection developing in
8
hospitalised patients in Northumbria Healthcare NHS Foundation Trust in 2008-
10 against target trajectory
4 Wards with outbreaks of diarrhoea and vomiting consistent with norovirus 9
infection
5 MSSA bacteraemias identified by Northumbria Healthcare NHS Foundation 10
Trust in 2010-11, split into pre- and post- 48 hour samples
6 Aggregated monthly compliance data for hand hygiene, IV device care plan use, 10
and commode cleanliness for April 2010-March 2011
7 Infection control audit compliance 11
4
4
4
4
5
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Executive summary
Healthcare associated infection (HCAI) continues to be a priority for the NHS. The
number of meticillin resistant Staphylococcus aureus (MRSA) bacteraemias and
Clostridium difficile cases occurring in a Trust are used as performance indicators and
there are targets to reduce the number of cases.
Within Northumbria Healthcare NHS Foundation Trust, infection prevention and
control is seen as a high priority, with engagement and ownership at all levels from
board to ward. Improvement programmes to reduce the number of MRSA
bacteraemias and C.difficile cases continue to be implemented. These have resulted
in a 33% reduction in the number of cases of MRSA bacteraemia developing 48 hours
or more after admission, in 2010-11 compared to 2009-10. The number of cases of
C.difficile in those aged 2 years and over, where the infection has developed in
hospital has been reduced by 25% during 2010-11 compared to 2009-10.
Following a self-assessment, the Trust declared itself compliant with the Health and
Social Care Act 2008 Code of Practice for the Prevention and Control of Healthcare
Associated Infections (the Hygiene code) by having appropriate systems in place to
protect patients, staff and the public from healthcare associated infection.
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1. Introduction
This is the Infection Prevention and Control Annual Report for Northumbria Healthcare
NHS Foundation Trust, produced by Dr Bryan Marshall, Director of Infection
Prevention and Control (DIPC) as required by the Health and Social Care Act 2008
Code of Practice for the Prevention and Control of Healthcare Associated Infection
(Hygiene Code).
The report details the structures and systems in place, and actions taken, to protect
patients, staff and the public from healthcare associated infection. It covers the period
April 2010 to March 2011.
2. Infection Prevention and Control Structures
Trust Board
The delivery of excellence in safety and quality is a high priority for Northumbria
Healthcare NHS Foundation Trust. The Trust Board of Northumbria Healthcare NHS
Foundation Trust has the collective responsibility for ensuring that the risks of infection
in the organisation are minimised and that the general means by which it prevents and
controls such risks are in place. The Board provides strategic leadership to ensure the
effective delivery and management of patient safety in relation to infection prevention
and control. Infection prevention and control is embedded into strategic planning and
thus into service delivery across the Trust. The Director of Infection Prevention and
Control (DIPC) is directly accountable to the Chief Executive and Trust Board, and
provides regular reports to the Board on compliance with infection control standards,
and on progress in delivering reductions in MRSA bacteraemias and Clostridium
difficile infections.
Infection Prevention and Control Team
The Infection Control service is part of the Clinical Support and Cancer Services
Business Unit.
The Infection Prevention and Control Team is led by Dr Bryan Marshall, Director of
Infection Prevention and Control.
Infection Control Committee
The Infection Control Committee is responsible for the strategic planning of infection
prevention and control across Northumbria Healthcare NHS Foundation Trust, with full
consultation with all stakeholders. Membership of this committee includes broad
representation from Directorate Clinical Governance Leads, Modern Matrons, Estates,
Pharmacy, Occupational Health and the Infection Control team. The committee acts
as a source of expert advice to the Executive on Infection Prevention and Control
issues. It reviews information on rates of healthcare associated infections and ensures
appropriate policies and procedures are in place to minimise the risk. It endorses and
monitors the Infection Control Annual Programme, and the work of the MRSA
improvement programme and Clostridium difficile improvement programme.
The implementation of infection prevention and control improvement programmes is
delivered through modern matrons and clinical teams with guidance and support from
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the infection prevention and control team and infection control committee. Weekly
meetings are teleconferenced across the Trust and attended by modern matrons,
managers and the infection control team to review audit data, root cause analyses of
cases of HCAI and ensure the on-going implementation of high standards of infection
prevention and control.
Assurance Framework
The Trust’s Assurance Framework includes the risks, controls and related assurances
that underpin the delivery of the principal objectives and is monitored and updated by
the Assurance Committee on a quarterly basis reporting to the Trust Board. Risks
associated with Infection Control that may affect the Trust achieving its corporate
objectives appear on the Assurance Framework.
The Infection Control risk register (which is part of the Clinical Support and Cancer
Services Business Unit risk register), is reported to the Infection Control Committee
and also to the Clinical Support Operational Board with high risks reported to the
Assurance Committee on a quarterly basis as part of the Trust wide risk register.
The Director of Infection Prevention and Control is a core member of the Assurance
Committee, reports directly to the Chief Executive and regularly to the Board on
infection prevention and control performance.
The Director of Infection Prevention and Control is also a member of the Safety and
Quality Committee, and provided presentations to the committee on a quarterly basis.
The minutes of the Infection Control Committee are presented to the Safety and
Quality Committee.
All Infection Control policies are ratified by the Assurance Policy Group, after approval
by the Infection Control Committee.
The Trust is required to comply with various national standards regarding infection
control. These include the Health and Social Care Act 2008, and NHSLA risk
management standard. The Trust is registered with the Care Quality Commission with
regard to healthcare associated infection.
3. Health and Social Care Act 2008 (Hygiene code)
The Health and Social Care Act 2008 Code of Practice for the Prevention and Control
of Healthcare Associated Infections was updated in December 2009 to include 10
compliance criteria, which Trusts were required to comply with. Based on self
assessment of these compliance criteria, the Trust declared itself to be compliant with
these standards. The Trust has had unconditional registration with the Care Quality
Commission from 1 st April 2009, with regard to infection control.
The DIPC collates evidence on a regular basis, to show continued compliance with the
relevant standards. This evidence is reviewed by the Infection Control Committee and
by the Assurance Committee on a quarterly basis. This evidence is shown in
appendices 1 and 2.
4. NHSLA
In December 2009, the Trust achieved NHSLA standard level 3, including full
compliance for both standard 4.9 Infection Control and standard 2.8 Hand Hygiene
training. The Trust has not been reassessed against these standards during 2010-11.
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5. Annual Programme 2010-11
There were 18 objectives in the infection control annual programme for 2010-2011.
These formed the focus for the work of the infection prevention and control team and
cover objectives such as the delivery of the MRSA and C.difficile improvement
programmes, compliance with the Health and Social Care Act 2008, education,
training and audit, ensuring compliance with national guidance and co-operation with
outside agencies.
Progress towards completion of these objectives was regularly monitored by the
infection control team and the infection control committee throughout the year.
Satisfactory progress was made towards completion of all the objectives. Many of the
objectives are ongoing activities, such as audit and training, and these will continue to
be delivered in future years. The programme and progress made is detailed in
appendix 3.
6. Annual Programme 2011-12
The infection prevention and control annual programme for the acute services for
2011-12 was approved by the Infection Control Committee in March 2011. A copy of
the objectives is included as appendix 4.
7. Service Improvement – MRSA improvement
programme
Since the Secretary of State for Health issued new targets for MRSA bloodstream
infections in acute NHS Trusts in England in November 2004, huge improvements
have been made in reducing MRSA bacteraemias in England.
Figure 1 shows the data for Northumbria Healthcare NHS Foundation Trust for the last
6 years. For the period April 2005 to March 2010, the target was based on all cases of
MRSA bacteraemia, community and hospital acquired, identified by Northumbria
Healthcare NHS Foundation Trust. For 2010-11, the target only included hospital
acquired cases, defined as those taken 48 hours or more after admission. The final
total for 2010-11 was 4 hospital acquired cases, against a target of 7 cases.
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Figure 1: MRSA bacteraemias identified by Northumbria Healthcare NHS Foundation Trust compared
to target, for period April 2002 to March 2011.
90
MRSA bacteraemias - actual v target
target actual (counted against target) post 48hrs
80
79
70
60
50
59
54
52 52
40
30
20
41
37
33
27
30
21
25
10
0
12
11
6
7
4
2005-06 2006-07 2007-08 2008-09 2009-10 2010-11
The data for the last 6 years shows a steady and sustained reduction in the number of
cases of hospital acquired MRSA bacteraemias. In the first year of the MRSA
bacteraemia improvement programme, 75% of cases were classified as hospital
acquired. In 2010-11, there were more community acquired MRSA bacteraemias
identified than hospital acquired MRSA bacteraemias, as shown in figure 2.
Figure 2: Timing of specimen collection in relation to admission for MRSA bacteraemias
MRSA bacteraemias identified by Northumbria lab
70
60
50
40
30
20
10
0
2005-06 2006-07 2007-08 2008-09 2009-10 2010-11
MRSA Pre-48hrs
MRSA Post-48hrs
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The work of the MRSA improvement programme continues, with the action plan
regularly reviewed and updated with issues identified through root cause analysis
which is undertaken for all cases of MRSA bacteraemia.
8. Service Improvement – Clostridium difficile
improvement programme
National mandatory surveillance of Clostridium difficile infection in those aged 65
years and over commenced in January 2007. The target was changed from April 2008
by splitting those cases developing in hospital from those developing in the community
and extended to include all those aged 2 years and over. Hospital apportioned cases
were defined as those where the faecal specimen was collected more than 2 days
after admission. Figure 3 shows the performance against target since April 2008.
Figure 3: Number of newly diagnosed cases of C.difficile infection developing in hospitalised patients in
Northumbria Healthcare NHS Foundation Trust in 2008-10 against target trajectory
Trust apportioned C.difficile cases - actual v target
target
actual
300
250
200
254
232
221
150
100
129
124
103
50
0
2008-09 2009-10 2010-11
Appropriate management of cases continues to be delivered through the use of an
integrated care plan for use by all staff groups involved in the care of a patient and a
weekly multi-disciplinary team meeting which reviews the care of all patients with
C.difficile infection in the Trust. Root cause analysis is undertaken for all hospital
acquired cases of C.difficile. The action plan to further reduce the number of cases, is
reviewed and revised on a regular basis. Plans for 2011-12 include measures to
further improve environmental cleanliness.
9. Service improvement - Surgical Site Infection
improvement programme
The Trust undertakes surveillance of surgical site infections following prosthetic knee
and hip replacement and hip hemiarthroplasty, as part of the national surveillance
scheme. This data is published by the Health Protection Agency and is available on its
website. A surgical site infection project group has developed and is delivering an
improvement programme.
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10. Outbreaks
Norovirus was again prevalent during 2010-11. Numerous outbreaks of gastroenteritis
caused by norovirus occurred throughout the year both in hospital and the community.
The high incidence in the community, especially in nursing and residential homes
resulted in many hospital outbreaks following the admission of patients from the
community with diarrhoea and vomiting.
The Infection Control Team worked with Trust management, bed management, ward
staff, domestics and other support staff to ensure that these outbreaks were contained
as quickly as possible. A list of wards affected is given in figure 4.
Figure 4: Wards with outbreaks of diarrhoea and vomiting consistent with norovirus infection
Month North
Tyneside
General
Wansbeck
General
Hospital
Community
hospitals
Hexham
General
Hospital
No. of
symptomatic
patients
No. of
symptomatic
staff members
Hospital
Apr-10 wards 6 & wards 2, 8 Berwick nil 48 3
8
& 17 Dewar ward
May-10 ward 8 wards 2, 8 nil nil 32 1
& 22
Jun-10 nil ward 3 nil ward 4 33 4
Jul-10 nil wards 2 & nil nil 18 2
22
Aug-10 nil nil nil nil 0 0
Sep-10 nil nil nil nil 0 0
Oct-10 nil nil nil nil 0 0
Nov-10 nil nil nil nil 0 0
Dec-10 nil nil nil nil 0 0
Jan-11 nil nil nil nil 0 0
Feb-11 wards 5,
8, 9, 12 &
24
Mar-11 wards 2,
12, 14 &
18
wards 2,
6, 7 & 8
wards 3, 5
& 22
Haltwhistle,
Blyth wards
2 & 3
wards 2 &
3
206 61
Blyth ward 1 nil 85 16
Four outbreaks due to Clostridium difficile were detected, affecting 3 patients at North
Tyneside General Hospital in June 2010, 3 patients at North Tyneside General
Hospital in October 2010, 3 patients at Wansbeck General Hospital in October 2010
and 5 patients at North Tyneside General Hospital in February 2011.
The infection control team, working with colleagues from the Health Protection
Agency, also identified and managed a cluster of cases of Listeria infection, and a
cluster of cases of infection/colonisation with a strain of carbapenemase-producing
Klebsiella pneumoniae.
11. Other surveillance programmes
In October 2010, the Department of Health announced that it was going to extend the
mandatory surveillances to include meticillin sensitive Staphylococcus aureus (MSSA)
bacteraemias and E.coli bacteraemias. The surveillance of MSSA bacteraemias
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commenced in January 2011, with E.coli bacteraemia surveillance starting in June
2011.
The data for MSSA bacteraemias for Northumbria Healthcare NHS Foundation Trust
for 2010-11 is shown in figure 5.
Figure 5: MSSA bacteraemias identified by Northumbria Healthcare NHS Foundation Trust in 2010-11,
split into pre- and post- 48 hour samples
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Total
10 10 10 10 10 10 10 10 10 11 11 11
Pre 2 3 2 5 3 2 3 3 2 3 3 4 35
48Hrs
Post
48Hrs
1 1 2 2 1 0 2 2 4 1 3 1 20
total 3 4 4 7 4 2 5 5 6 4 6 5 55
12. Audit
Wards and departments undertake weekly audits of hand hygiene, commode
cleanliness, and intravascular device care. The data is reviewed at the weekly
healthcare associated infection meetings, and deficiencies addressed by the Modern
Matron responsible for the area concerned. Spot checks by the infection control team
validate the data submitted by the wards. The aggregate monthly data is shown in
figure 6.
Figure 6: Aggregated monthly compliance data for hand hygiene, IV device care plan use, and
commode cleanliness for April 2010-March 2011
Trust Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
standard
Hand hygiene >95% 98.1
%
97.3
%
97.3
%
97.1
%
97.8
%
97.1
%
97.8
%
98.0
%
97.4
%
97.1
%
96.9
%
97.4
%
IV device care plan >95% 96.8
%
98.2
%
99.1
%
98.6
%
99.3
%
98.9
%
98.7
%
99.1
%
98.8
%
98.2
%
98.8
%
99.7
%
Commode
cleanliness
≥98% 98.6
%
97.6
%
96.7
%
98.2
%
99.1
%
98.7
%
98.7
%
98.9
%
98.2
%
98.7
%
98.0
%
99.1
%
Trust-wide audits of compliance with the MRSA policy and the C.difficile policy and of
the care of central venous catheters were undertaken. Overall there was good
compliance with these policies.
There is a regular rolling programme of audits for all wards and departments, using
the Infection Control Nursing Association audit tools, which is coordinated by the
infection control team. This tool kit sets a level of 85% as compliant with the audit
standard. Action plans are implemented in those areas falling below standard.
The aggregated Trust wide results for the period April to December 2010, with
comparable data for preceding years, are shown in figure 7. In reviewing the audit
programme and tools in December 2010, it was decided that the infection control
nurses would focus on auditing those aspects related to clinical care, with the
environmental aspects picked up by the domestic monitoring team.
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Figure 7: Infection Control Audit Compliance
IC audit compliance
2006/07 2007/08 2008/09 2009/10 Apr-Dec 2010
105%
average compliance
100%
95%
90%
85%
80%
75%
70%
91%
92%
95%
93%
96%
93%
95%
97%
97%
97%
95%
95%
97%
97%
99%
97%
98%
92%
97%
98%
94%
96%
96%
96%
96%
94%
96%
98%
98%
99%
93%
94%
95%
95%
97%
89%
91%
91%
92%
91%
87%
91%
90%
91%
92%
92%
94%
95%
95%
96%
65%
60%
Departmental
w aste
Hand hygiene
Handling and
disposal of
linen
Isolation
precautions
Patient
equipment
(general)
Personal
protective
equipment
Safe handling
and disposal
of sharps
Ward
environment
Ward kitchen
All ICNA audits
13. Education and training
Infection prevention and control advice and information continues to be given to all
new staff on their first day at work prior to commencing clinical duties as part of the
induction video. The infection control section includes standard precautions and hand
hygiene training. E-learning packages are used for all junior doctors.
Mandatory training sessions have continued and attendance is monitored on a
monthly basis. All staff are required to undergo hand hygiene training every two years.
Over 2800 staff received hand hygiene training between April 2010 and March 2011.
Infection control responsibilities are included in all job description and is one of the
elements considered at annual appraisal.
An infection control road show visited all Trust sites, during September and October
2010, to raise awareness of hand hygiene and norovirus infection amongst staff,
patients and visitors.
An infection control study day for domestic staff was held at Cobalt in September
2010.
The annual infection control study day for nursing and allied health professionals was
planned to take place on 2 nd December 2010 in the education centre at Hexham
General Hospital. Unfortunately the adverse weather conditions meant that the event
had to be postponed, and was rescheduled for May 2011.
Development opportunities for the members of the infection prevention and control
team are agreed at annual appraisal.
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14. Decontamination and cleanliness
Environmental cleanliness is monitored through the National cleanliness scores and
PEAT scores. These are consistently high, with any exceptions reported to the weekly
healthcare associated infection meeting. Domestic service arrangements will be
reviewed during 2011-12 as part of the work to further reduce cases of Clostridium
difficile infection.
15. Antibiotic stewardship
The use of antibiotics is one of the key drivers for the increase in antibiotic resistance.
Control of antibiotic use is therefore an important part of the control measures to
reduce infection caused by antibiotic resistant organisms. Ensuring the
appropriateness of antibiotic prescribing is a key component in reducing healthcare
associated infection. In line with National guidance to reduce the risk of C.difficile
infection, the use of certain antibiotics, such as cephalosporins and fluoroquinolones is
strictly controlled within the Trust.
16. Patient and public involvement
It is important that patients and the public are informed about and involved in infection
prevention and control activities. Patient information leaflets continue to be reviewed
and updated. Good hand hygiene compliance is a fundamental part of the delivery of
safe healthcare and remains a Trust priority. Alcohol gel dispensers and prominent
signage at the hospital entrances as well as departmental and ward entrances,
promote hand hygiene to patients and visitors, as well as staff. Manned stalls at the
hospital entrances during the infection control road shows raised awareness of hand
hygiene and norovirus amongst staff, patients and visitors. Trust Board reports, which
include information on infection prevention and control are publicly available on the
internet site.
There is patient and public governor representation on the MRSA and C.difficile
steering groups.
17. North of Tyne Healthcare Associated Infection Group
The North of Tyne Healthcare Associated Infection Group has representatives from all
NHS healthcare providers North of Tyne. The DIPC and lead nurse for infection
control represent Northumbria Healthcare on this group. The aim of the group is to
support and facilitate cross organisational working covering the whole health
economy, to achieve sustainable reductions of MRSA bacteraemias and Clostridium
difficile.
18. Safer Care North East
Safer Care North East was a 3 year strategy, lead by the North East SHA to improve
patient safety. Healthcare Associated Infection as one of the eight clinical themes for
which a programme of interventions was defined. An HCAI taskforce was formed and
identified objectives, goals, initiatives and measures. Representatives from most NHS
organisations across the region were involved in the programme. The DIPC for
Northumbria Healthcare NHS Foundation Trust acted as the clinical chair for this
group.
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19. The future
Infection prevention and control will continue to be a key element of the patient safety
agenda. The MRSA bacteraemia target and the C.difficile reduction target will
continue to be major drivers for improvement in infection prevention and control.
The introduction of surveillance systems for MSSA bacteraemias and E.coli
bacteraemias during 2011 will provide further data and may identify further work that
can be done to improve patient safety.
External scrutiny of infection prevention and control will involve the Care Quality
Commission through compliance with the Health and Social Care Act 2008 code of
practice (Hygiene Code), and by delivery of MRSA bacteraemia and C.difficile
reduction targets as set by North of Tyne Commissioners.
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Appendix 1 Health and Social Care Act 2008 compliance self assessment
Safeguarding and safety
Outcome 8 (Regulation 12):
Cleanliness and infection control
Providers of services comply with the requirements of regulation 12, with regard to
the Code of Practice for health and adult social care on the prevention and control
of infections and related guidance.
8A
Provide evidence to demonstrate that you are
complying with the Code of Practice for health and
adult social care on the prevention and control of
infections and related guidance.
Green
x
Yellow Amber Red
Summary of evidence to support the outcomes described in 8A
Criterion 1: Systems to manage and monitor the prevention and control of infection.
Processes
- The Trust Board has a collective responsibility to approve and self-certify the Trust's
Annual Plan.
- Policy IC01 Infection control operational policy describes the infection prevention and
control structures in the Trust and details the assurance framework.
- The Trust has a Director of Infection Prevention and Control accountable directly to the
Chief Executive.
- An annual programme is produced.
- An audit programme is in place.
- Training and information is delivered to all staff.
- There is an executive lead for decontamination.
- The Risk Register details identified risks, and required actions to reduce or control the
risk. The Risk Registers are regularly reviewed
- Action plans are produced and their delivery monitored
-The DIPC is accountable directly to the Chief Executive and the Board
- The DIPC leads the infection control team and chairs the infection control committee
- The DIPC overseas the development and implementation of infection control policies
- The DIPC is a member of the Trust's Assurance Committee and Safety and Quality
Committee
- The DIPC produces an Annual Report which is available on the Trust's internet site. The
report includes surveillance data, audit data and progress against annual programme of
activity.
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- The Trust Board receives regular updates from the DIPC and Modern Matrons
- Surveillance data for healthcare associated infections is presented to the infection
control committee every two months. Infection related serious untoward incidents are
reviewed through the appropriate clinical governance processes
- Root cause analysis is undertaken for every MRSA bacteraemia and C.difficile case.
Lessons learnt are disseminated via the business units, and used to inform the MRSA and
C.diffcile action plans
- The Infection Control Team is led by the DIPC, and includes specialist nurses, and
medical microbiologists, with administrative and analytical support. 24 hour cover is
provided by consultant medical microbiologists.
- Bed management operational guidance and the infection control isolation policy ensure
that appropriate movement and placement of patients. Daily review of high risk patients is
undertaken by the infection control team and clinical staff. PAS alert codes facilitates the
identification of patients previously positive for MRSA and/or C.difficile. Admission
screening for MRSA identifies patients admitted with MRSA. Transfer and Discharge
policy and associated documentation ensures the appropriate transfer of information when
patients move between healthcare facilities/providers.
Outcome measures
Incidence of MRSA bacteraemias (hospital acquired)
Incidence of C.difficile cases (hospital acquired)
Audits
- Commode cleanliness
- Hand hygiene
- IV cannulation compliance (care plan)
- Antibiotic prescribing compliance
- Mattress integrity
- MRSA policy compliance
- C.difficile policy compliance
- ICN environmental audits
- departmental waste
- hand hygiene
- handling and disposal of linen
- isolation precautions
- patient equipment (general)
- personal protective equipment
- safe handling and disposal of sharps
- ward environment
- ward kitchen
CQC inspection reports
NHS LA standards (criterion 4.9)
Orthopaedic surgical site infection surveillance
Criterion 2: Provide and maintain a clean and appropriate environment in managed
premises that facilitates the prevention and control of infections.
Processes
- there are designated leads for decontamination and for cleaning
- lead for cleaning liaises closely with Director of Nursing, Modern Matrons and ICT in all
aspects of service planning and delivery
- Modern Matrons are responsible and accountable for ensuring a safe and clean care
environment
- Action plans are formulated to address any issues identified through PEAT inspections
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- Regular monitoring of cleanliness, using National Cleanliness scores, is undertaken and
results reported back through business units and to Trust Board
- Cleaning schedules displayed in all clinical areas
- There are adequate hand hygiene facilities in clinical areas, including point of care
alcohol hand rub
- There are procedures in place for the cleaning of commodes and mattresses, backed up
by audit processes
- There are contracts in place for the supply and provision of linen and laundry
- Policies and procedures are in place to ensure appropriate levels of cleanliness, building
and refurbishment work is undertaken to an appropriate standard, for waste management,
pest control, minimise risk of legionella, for food services and for planned preventative
maintenance
- The Trust has a cleaning strategy, which incorporates National Cleaning Standards, and
the operational cleaning plan identifies specific roles
- Cleaning schedules are publicly displayed
- Procedures are in place to enable staff to request additional cleaning when required
- There is a Cleaning and Disinfection policy, which details the different cleaning and
disinfection requirements of equipment
- Most of the decontamination of re-usable medical devices is undertaken in centralised
facilities (CSSD), with some local reprocessing (endoscopes)
- Traceability system in place
- Part of competency assessment in medical device training covers the
cleaning/decontamination
Outcome measures
National Cleanliness score
Audits
- Commode cleanliness
- MRSA policy compliance
- C.difficile policy compliance
- ICN environmental audits
- departmental waste
- hand hygiene
- handling and disposal of linen
- isolation precautions
- patient equipment (general)
- personal protective equipment
- safe handling and disposal of sharps
- ward environment
- ward kitchen
CQC inspection reports
PEAT scores
- infection control
- specific cleanliness (all areas except patient equipment and waste receptacles)
- specific cleanliness (patient equipment)
- specific cleanliness (waste receptacles)
- toilet and bathroom cleanliness (excluding patient equipment and waste receptacles)
- toilet and bathroom cleanliness (patient equipment)
- toilet and bathroom cleanliness (waste receptacles)
- environment (waste handling)
- environment (linen)
National inpatient survey
- availability of hand wash gel for patients and visitors to use
- describing the hospital rooms or wards as clean
- describing the toilet and bathrooms as clean
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National outpatient survey
- cleanliness of outpatient department
- cleanliness of toilets
NHS Staff Survey
- key finding 20 (hand wash materials always available)
Criterion 3: Provide suitable accurate information on infections to service users
and visitors.
Processes
- Information on infections is provided to service users and their visitors through a number
of routes
- there is a dedicated section on the Trusts internet site covering infection prevention and
control (www.infectioncontrolnorthumbria.nhs.uk)
- the DIPC’s annual report is available on the Trust’s internet site
- infection control data and information is displayed in patient areas
- patient information leaflets are available, which have been reviewed by a readers panel
- involvement and empowerment of patients and visitors (hand hygiene is promoted to
patient and visitors through display boards and twice yearly promotional events)
- involvement of patient representative and governors in MRSA and C.difficile
improvement programmes.
- there is a telephone hotline for patients and visitors to report failures in cleanliness
standards
Outcome measures
Incidence of MRSA bacteraemias (hospital acquired)
Incidence of C.difficile (hospital acquired)
CQC inspection reports
National Inpatient survey
- posters or leaflets asking patients and visitors to wash hands or use hand wash
gel
NHS Staff survey
- The Trust does enough to promote the importance of hand washing to patients, service
users and trust visitors
Orthopaedic surgical site infection surveillance
Criterion 4: Provide suitable accurate information on infections to any person
concerned with providing further support or nursing/medical care in a timely
fashion.
Processes
- patients are provided with information leaflets to take home when discharged
- transfer and discharge communication includes relevant information on infections
Outcome measures
Audits
- MRSA policy compliance
- C.difficile policy compliance
Criterion 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.
Processes
- procedures are in place to identify patient who have or who develop infections are
identified promptly.
Page 17 of 33

- treatment guidelines are in place to ensure infections are treated properly
- Consultant microbiologist advice is available 24hours a day, 7 days a week
- procedures are in place to report MRSA bacteraemias, and C.difficile cases to the HPA
as part of mandatory surveillance
- notifiable diseases and outbreaks are reported to the local health protection unit
- MRSA bacteraemias and C.difficile associated deaths are reported as SUIs
- screening procedures are in place to identify patients colonised with MRSA
- the responsibility for infection prevention and control is included in all employees’ job
descriptions
Outcome measures
MRSA screening compliance (elective, emergency)
Criterion 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.
Processes
- the responsibility for infection prevention and control incorporated in all employees’ job
descriptions.
- good cross organisation working - mutual support for PCT ICNs, mental health trust.
North of Tyne HCAI cluster meetings held months.
- infection prevention and control included in Induction for all new staff, including
contractors and agency staff.
Outcome measures
Audits
- hand hygiene
- ICN environmental audits
- personal protective equipment
- safe handling and disposal of sharps
CQC inspection reports
NHS LA standards (criterion 4.9)
NHS Staff survey
- key finding 19 (hand wash materials always available)
- the Trust does enough to promote the importance of hand washing to staff
- the Trust does enough to promote the importance of hand washing to patients, service
users and trust visitors
- infection control applies to me
Criterion 7: Provide or secure adequate isolation facilities.
Processes
- the side rooms that are available are detailed in major outbreak plan.
- IC involved in all new builds/ward refurbishments.
- isolation policy prioritises need for side rooms. Also included in bed management
operational protocol.
- potential use of cohort nursing detailed in infection control policies.
- daily meetings between infection control, bed managers and matrons reviews the need
for isolation of individual patients.
Outcome measures
Audits
- C.difficile policy compliance
- ICN environmental audits
- isolation precautions
Page 18 of 33

Criterion 8: Secure adequate access to laboratory support as appropriate.
Processes
- the microbiology is a CPA accredited laboratory (currently conditional accreditation)
Outcome measure
Successful CPA accreditation
Criterion 9: Have and adhere to policies, designed for the individual’s care and
provider organisations, that will help to prevent and control infections.
Processes
- The following policies are in place:
- IC01 Infection Control Operational policy
- IC02 Hand Hygiene policy
- IC03 Standard Precautions policy
- IC04 Needlestick injury policy
- IC05 Patient Isolation policy
- IC06 Major Outbreak policy
- IC07 MRSA policy
- IC08 CJD policy
- IC09 TB policy
- IC10 Management of meningococcal disease policy
- IC11 Cleaning and Disinfection policy
- IC12 Single Use Equipment policy
- IC14 Ward Beverage Bay policy
- IC15 Ice Making machines and water cooler policy
- IC16 Intravascular device policy
- IC17 Prevention and management of dust in hospital environment policy
- IC18 Ectoparasitic infection policy
- IC19 Linen policy
- IC21 SARS policy
- IC22 Legionella policy
- IC23 Hepatitis C policy
- IC24 Surveillance strategy
- IC25 GRE policy
- IC26 C.difficile policy
- IC27 Infection Control Guidelines for Pandemic Flu Management
- IC28 Aseptic technique policy
- IC29 Employment screening policy on HIV infection
- IC30 Viral Haemorrhagic Fever policy
- IC31 Multi-resistance Gram negative bacteria including Acinetobacter policy
- IC32 Glove policy
- CG46 Policy for the Prudent Use of Antimicrobial drugs
- RMP06 Waste management policy
- RMP12 Management of medical devices policy
- RMP31 Medical devices training policy
- PP23 Immunisation/screening policy
- PP30 Dress code and uniform policy
Outcome measures
Audits
- hand hygiene
- IV cannulation compliance (care plan)
- Antibiotic prescribing compliance
Page 19 of 33

- MRSA policy compliance
- C.difficile policy compliance
- ICN environmental audits
- departmental waste
- hand hygiene
- handling and disposal of linen
- isolation precautions
- patient equipment (general)
- personal protective equipment
- safe handling and disposal of sharps
- ward environment
- ward kitchen
‘2 minutes of your time’ Infection Control questionnaire
- Q5 “have you ever seen staff in this hospital washing their hands during your
stay/visit”
PEAT scores
- specific cleanliness (waste receptacles)
- toilet and bathroom cleanliness (waste receptacles)
- environment (waste handling)
- environment (linen)
National Inpatient survey
- noticed that nurses washed or cleaned their hands between touching patients
- noticed that doctors washed or cleaned their hands between touching patients
Criterion 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 care.
Processes
- all staff have access to occupational health services.
- occupational health team undertake risk assessment for all staff and offer immunisation
as appropriate (policy PP23 immunisation/screening policy)
- occupational health screening includes exposure prone procedure clearance
assessment
- IC04 Needlestick injury policy details action taken in the event of occupational exposure
to blood and blood stained body fluids. This is delivered through occupational health
during office hours and via A&E out-of-hours
- Infection prevention and control is included as part of induction for all new staff and as
part of mandatory training requirement. Training records are held by the training
department.
- Infection prevention and control responsibility is included in the job description for all
employees, and is considered as part of appraisal/personal development plans
Outcome measures
Infection prevention and control training (hand hygiene)
Audits
- ICN environmental audits
- safe handling and disposal of sharps
NHS LA standards (criterion 2.8)
NHS LA standards (criterion 3.6)
NHS LA standards (criterion 4.9)
NHS Staff survey
- the Trust does enough to promote the importance of hand washing to staff
- infection control applies to me
Page 20 of 33

Appendix 2 Health and Social Care Act 2008 Outcome 8 (cleanliness and infection control) outcome measures
Outcome Measure 8 Hygiene
code
Latest Trust NTGH WGH HGH Halt MCH BCH FC TC Aln Ber Roth Red
criteria
National Cleanliness score 2 Mar11 98% 98% 96% 98% 97% 95% 97% 99% 98% 98% 98% 98% 100%
Incidence of MRSA
bacteraemia (hosp.
acquired cases)
Incidence of C.difficile
(hosp. acquired cases)
MRSA screening
compliance (elective patients)
MRSA screening
compliance (emergency
patients)
Commode cleanliness
Page 21 of 33
1, 3 Apr10-
Mar11
4 1 2 1
1, 3 Apr10-
Mar11
103 54 26 5 2 6 4 3 3
5 Mar11 115.7
%
5 Mar11 103.2
%
1, 2 Mar11 99.1% 98.1% 100% 100% 100% 100% 100% 100% 100% 95.0% 100% 100%
audits
Hand hygiene audits 1, 6, 9 Mar11 97.4% 96.9% 95.4% 99.6% 100% 100% 96.0% 98.8% 100% 96.7% 98.6% 100% 94.9%
IV cannulation compliance 1, 9 Mar11 99.7%
– care plan in use
Antibiotic prescribing 1, 9 Dec10 93.3%
compliance audits
Infection Prevention and
Control Training (hand
hygiene)
10 Dec10 86.6% 82.8% 87.4% 87.4% 100% 98.5% 100% 94.8% 91.9% 100%
Mattress integrity audits 1, 2 Mar11 100% 100%
(Mar 11)
99%
MRSA policy compliance
audit
- standard precautions in place
MRSA policy compliance
audit
- patient receiving
decolonisation therapy as per
policy
MRSA policy compliance
audit
- staff aware of terminal
cleaning process once
isolation discontinued
MRSA policy compliance
audit
- area had MRSA information
leaflet available for patients
and visitors
1, 9 Nov-
Dec10
1, 9 Nov-
Dec10
1, 2, 9 Nov-
Dec10
4 Nov-
Dec10
81%
100%
100%
100%
(Mar 11)
100%
(Mar 11)
100%
(Mar11)
100%
(Feb 11)
100%
(Mar 11)
100%
(Mar 11)
100%
(Mar11)
100%
(Feb 11)
100%
(Mar11)

C.difficile policy compliance
audit
- isolated in cubicle with
standard precautions in place
C.difficile policy compliance
audit
- integrated care pathway in
use
C.difficile policy compliance
audit
- twice daily cleaning
C.difficile policy compliance
audit
- area had C.difficile
information leaflets available
for patients and visitors
ICN environmental audits
- departmental waste
ICN environmental audits
- hand hygiene
ICN environmental audits
- handling and disposal of
linen
ICN environmental audits
- isolation precautions
ICN environmental audits
- patient equipment
(general)
ICN environment audits
- personal protective
equipment
ICN environmental audits
- safe handling and
disposal of sharps
ICN environmental audits
- ward environment
ICN environmental audits
- ward kitchen
“2 minutes of your time”
Infection control
questionnaire – Q5 “have
Page 22 of 33
Hygiene
code
criteria
Latest Trust NTGH WGH HGH Halt MCH BCH FC TC Aln Ber Roth Red
1, 7, 9 Nov- 100%
Dec10
1, 9 Nov-
Dec10
1, 2, 9 Nov-
Dec10
4 Nov-
Dec10
1, 2, 9 Apr09-
Mar10
1, 2, 9 Apr09-
Mar10
1, 2, 9 Apr09-
Mar10
1, 2, 7, 9 Apr09-
Mar10
1, 2, 9 Apr09-
Mar10
1, 2, 6, 9 Apr09-
Mar10
1, 2, 6, 9,
10
Apr09-
Mar10
1, 2, 9 Apr09-
Mar10
1, 2, 9 Apr09-
Mar10
9 Feb-
Mar10
100%
100%
100%
93% 93% 93% 95% 100% 83% 93% 95% 81% 96% 90% 91%
97% 97% 96% 97% 95% 98% 96% 97% 90% 98% 96% 100%
97% 97% 95% 100% 100% 100% 95% 100% 100% 98% 99% 100%
97% 99% 94% 100% 100% 98% 93% 100% 93% 92% 100% 100%
95% 96% 97% 99% 100% 94% 94% 93% 93% 98% 98% 92%
98% 99% 98% 98% 100% 100% 98% 100% 93% 100% 96% 100%
95% 97% 94% 98% 96% 93% 90% 80% 96% 97% 94% 95%
92% 91% 89% 94% 98& 87% 93% 96% 98% 92% 97% 97%
91% 93% 87% 93% 100% 87% 92% 88% 83% 88% 94% 100%
yes=
81.1%,
no=
8.6%,

you ever seen staff in this
hospital washing their hands
during your stay/visit”
Hygiene code inspection /
follow up – no. of
outstanding areas for
improvement
NHS LA standards
- criterion 2.8
NHS LA standards
- criterion 3.6
NHS LA standards
- criterion 4.9
PEAT score for Infection
Control (proportion of
applicable wards with hand
wash basins)
PEAT score for Infection
Control (proportion of
applicable wards with
adequate hand
decontamination provision)
PEAT score for specific
cleanliness (all areas
except patient equipment
and waste receptacles)
PEAT score for specific
cleanliness (patient
equipment)
PEAT score for specific
cleanliness (waste
receptacles)
PEAT score for toilet and
bathroom cleanliness
(excluding patient
equipment and waste
receptacles)
PEAT score for toilet and
bathroom cleanliness
Page 23 of 33
Hygiene
code
criteria
1, 2, 3, 6,
8
cannot
comme
nt/no
answer
=10%
Latest Trust NTGH WGH HGH Halt MCH BCH FC TC Aln Ber Roth Red
Oct /
Nov09
10 Dec09 Level
3
10 Dec09 Level
3
1, 6, 10 Dec09 Level
3
2 Jan-
Mar10
2 Jan-
Mar10
2 Jan-
Mar10
2 Jan-
Mar10
2, 9 Jan-
Mar10
2 Jan-
Mar10
2 Jan-
Mar10
0
9/9 9/9 9/9 3/3 3/3 6/6 2/2 5/5 5/5 3/3
9/9 9/9 9/9 3/3 3/3 6/6 2/2 5/5 5/5 4/4
excellen
t
excellen
t
excellen
t
excellen
t
excellen
t
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent

(patient equipment)
PEAT score for toilet and
bathroom cleanliness
(waste receptacles)
PEAT score for
environment (waste
handling)
PEAT score for
environment (linen)
Page 24 of 33
hygiene
code
criteria
2, 9 Jan-
Mar10
2, 9 Jan-
Mar10
2, 9 Jan-
Mar10
National cleanliness score 2 Jan-
Mar10
National inpatient survey
-posters or leaflets asking
patients and visitors to
wash hands or use handwash
gel
National inpatient survey
- availability of hand-wash
gel for patients and visitors
to use
National inpatient survey
- describing the hospital
rooms or wards as clean
National inpatient survey
- describing toilet and
bathrooms as clean
National inpatient survey
- noticed that nurses
washed or cleaned their
hands between touching
patients
National inpatient survey
- noticed that doctors
washed or cleaned their
hands between touching
patients
National outpatient survey
- cleanliness of outpatient
department
Latest Trust NTGH WGH HGH Halt MCH BCH FC TC Aln Ber Roth Red
3 2009 9.8/10
about
same
2 2009 9.7/10
about
same
2 2009 8.8/10
about
same
2 2009 8.6/10
about
same
9 2009 8.7/10
about
same
9 2009 8.6/10
about
same
2 2009 9.2/10
better
excellen
t
excellen
t
excellen
t
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
excell
ent
97% 95% 98% 99% 94% 94% 95% 94% 96% 99%

National outpatient survey
- cleanliness of toilets
NHS Staff survey
- key finding 19 (hand wash
materials always available)
NHS Staff survey
- the Trust does enough to
promote the importance of
hand washing to staff
NHS Staff survey
- the Trust does enough to
promote the importance of
hand washing to patients,
service users and trust
visitors
NHS Staff survey
- “infection control applies
to me”
Orthopaedic SSI
surveillance
- hip prosthesis (inpatient /
inpatient+readmission)
Orthopaedic SSI
surveillance
- knee prosthesis (inpatient
/ inpatient+readmission)
Orthopaedic SSI
surveillance
- repair of neck of femur (
inpatient /
inpatient+readmission)
2 2009 9.1/10
about
same
hygiene
code
criteria
Latest Trust NTGH WGH HGH Halt MCH BCH FC TC Aln Ber Roth Red
2, 6 2010 71% 72% 73% 82%
above
average
6, 10 2010 92%
3, 6 2010 86%
6, 10 2010 87%
1, 3 2008-
09
1, 3 2008-
09
1, 3 2008-
09
1.6%
/
3.4%
0.1%
/
1.3%
1.7%
/
2.1%
Key
NTGH
North Tyneside General Hospital
WGH Wansbeck General Hospital
HGH Hexham General Hospital
Halt Haltwhistle Hospital
MCH Morpeth Cottage Hospital
BCH Blyth Community Hospital
Page 25 of 33

FC Foxton Court
TC Tynemouth Court
Aln Alnwick Infirmary
Ber Berwick Infirmary
Roth Rothbury Cottage Hospital
Red Redesdale Court
Page 26 of 33

Appendix 3: Northumbria Healthcare NHS Foundation Trust
Infection Prevention and Control Annual Plan
April 2010 - March 2011 – progress report March 2011
No. Objective Actions Lead Date of
review
1 Undertake surveillance of MRSA
bacteraemias and C.difficile cases, and
disseminate data to clinical teams.
2 Identify and respond promptly to
clusters/outbreaks of infection in hospitals.
3 Ensure Trust is compliant with Care Quality
Commission registration criteria (Hygiene
Code)
Data updated and disseminated monthly via
business units, and to CPG as requested.
Data reviewed at ICC quarterly
Ensure that appropriate precautions are put
in place to control the further spread of
infection.
Review evidence of compliance on quarterly
basis
GI / BM
BM
ICT
BM /
ICC
Review
quarterly
Review
quarterly
Review
quarterly
Target
date
On-going
On-going
On-going
Progress report
data disseminated to business units. BM
gave update at May CPG. Weekly updates
for to execs, BUDs and through modern
matrons.
Surveillance reports to ICC
outbreaks dealt with in timely manner
evidence reviewed. Still compliant
4 Implement MRSA action plan to reduce
MRSA bacteraemias
5 Implement C.difficile action plan to reduce
number of C.difficile cases developing in
hospital
6 Contribute to the work plan to reduce the
incidence of post operative wound infection
following orthopaedic surgery
7 Audit activities
(see separate action plan) CS / BM Sep-10 Mar-11 action plan produced for Monitor – to be
reviewed through weekly meetings
(see separate action plan) DS / JS Sep-10 Mar-11 action plan being implemented. Overseen by
C.difficile steering group
Provide specialist advice and support to the
Improvement programme
All clinical areas to undertake an annual
infection control audit
All clinical areas to undertake regular hand
hygiene audits
All clinical areas to undertake regular audits
of peripheral IV devices
TO / RH Sep-10 Mar-11 work ongoing.
ICT /
Ward
manager
s
Ward
manager
s
Ward
manager
s
Sep-10 Mar-11 audits/action plans reported back through
weekly meeting
Apr-10 On-going audits underway and reviewed at weekly
meeting and by modern matrons
Apr-10 On-going audits underway and reviewed at weekly
meeting and by modern matrons
Undertake audits of policy compliance ICT Sep-10 Mar-11 audit of CVC (April10, Nov10), audit of CJD
(as part of medical record audit (June10).
MRSA and C.difficile audits (Dec10) to be
presented to ICC Mar2011
Page 27 of 33

8 Continue to enhance infection control as an
integral part of clinical governance and
patient safety throughout the organisation.
(Board to Ward)
9 Provide monthly performance reports to
Trust Board
10 Policy review
11 Hand hygiene promotion to staff, patients
and visitors
12 Education
Ensure that all risk registers are regularly
reviewed and updated to ensure that all
infection risks are highlighted
BU
governa
nce
leads
Jul-10 On-going
Written reports provided to Trust Board BM Jul-10 On-going written reports provided on monthly basis -
incorporated into performance reports
Review policies as required as new
guidance becomes available
ICT Jul-10 Mar-11
Review Outbreak policy DT Nov-10 May-11 Major outbreak policy to approved by ICC
Jan11 and by Assurance Policy Group
Jan11 , new policy – Diarrhoea and
Vomiting policy approved by ICC Nov10 and
by Assurance Policy Group Jan11
Review MRSA policy BM Nov-10 Nov-10 approved by ICC Sep10, approved by policy
group Nov10.
Review TB policy JS Nov-10 Nov-10 approved by ICC Jan11, and by Assurance
policy group Jan11
A twice yearly display at main entrances –
arranged via ICT and company
representatives
Deliver sufficient mandatory training
sessions to enable all staff to receive
infection prevention and control training
(including hand hygiene) every two years
13 Communication Ensure that there are robust systems of
communication between infection control
and all trust personnel.
14 Cleanliness and Decontamination issues Embed the use of hydrogen peroxide for
enhanced environmental cleanliness
ICT /
Compan
y reps
Sep-10,
Mar-11
hand hygiene and norovirus awareness
event held Sep-Oct10
ICT Sep-10 Mar-11 delivering sufficient sessions
Hold annual infection control study day ICT Nov-10 Nov-10 Study day for domestics held in September
at Cobalt. Study day for nursing staff and
AHP due to be held at HGH in December
had to be cancelled due to adverse weather
conditions. To be rescheduled.
ICT /
commu
nication
s team
V
Gingell
Jul-10 Nov-10 Regular input into Communications team
email updates. IC newsletters produced
(May and December). Intranet site updated
regularly. Development of SBAR system for
high risk patients.
Sep-10 Sep-10 hydrogen peroxide used as part of deep
cleaning process where possible
15 Building works Liaise with relevant personnel to ensure that
building works / new developments are
undertaken in a manner to minimise
infection risks
Page 28 of 33
ICT /
Estates
Sep-10 On-going Input into building works

16 Maintain service provision to external
contracts/SLAs
17 Public and patient involvement
18 Links to external bodies
Ensure NECC plans facilitate good infection
control practices
Service provided to Ramsay Medical (Cobalt
Treatment Centre)
Microbiologist support to ICT of
Northumberland, Tyne and Wear NHS Trust
Microbiologist support to ICT of
Northumberland Care Trust
Public/patient/governor representation on
MRSA and C.difficile steering groups
Displays/presentations to Governors as
requested
Patient Information leaflets – ensure
reviewed as required
Respond to enquiries from Media through
the Communications department
Paul
Brayson
/ BM
Jul-10 Sep-10 BM attending planning meetings
CS Oct-10 On-going Ramsay medical have decided to terminate
SLA as able to provide service from within
own organisation
BM Oct-10 On-going support provided.
BM Oct-10 On-going support provided
CS to
liaise
Sep-10 On-going governors attend MRSA and C.difficile
steering groups
ICT Sep-10 Mar-11 none requested
ICT /
Sandra
Guy
BM /
ICT
Sep-10 Mar-11
Sep-10 On-going responses provided
Service improvement questionnaire ICT Jan-11 questionnaire developed and circulated.
Results to be feedback to ICC March 11
Contribute to North of Tyne HCAI group BM / CS Jul-10 On-going BM and CS represent Trust
Contribute to North of Tyne Health
Protection Group
Contribute to SHA Safer Care HCAI
taskforce
VC Sep-10 On-going VC represents Trust
BM Jul-10 On-going BM is currently clinical chair of this group
Report infection related SUIs to SHA ICT Jul-10 On-going MRSA bacteraemias, C.difficile associated
deaths and C.difficile outbreaks reported as
SUIs
BM
GI
CS
VC
DS
JS
ICT
TO
RH
DT
Bryan Marshall
Giles Idle
Catherine Stokoe
Vicky Cleeve
Diane Sisterson
Jayanta Sarma
Infection control team
Tamsin Oswald
Ruth Henein
David Tate
B Marshall
Director of Infection Prevention and Control
3 rd March 2011
Page 29 of 33

Appendix 4 Northumbria Healthcare NHS Foundation Trust
Infection Prevention and Control Annual Plan for Acute Services
April 2011 - March 2012
No. Objective Actions Lead Date of review Target date
1 Undertake surveillance of MRSA bacteraemias,
C.difficile cases, MSSA bacteraemias and E.coli
bacteraemias, and disseminate data to clinical teams.
2 Identify and respond promptly to clusters/outbreaks of
infection in hospitals.
3 Ensure Trust is compliant with Care Quality
Commission registration criteria (Hygiene Code)
Data updated and disseminated monthly via business
units, to Safety and Quality Committee quarterly, and to
CPG as requested.
Data reviewed at ICC quarterly
Ensure that appropriate precautions are put in place to
control the further spread of infection.
GI / BM
Review evidence of compliance on quarterly basis BM /
ICC
Review quarterly
On-going
BM
ICT Review quarterly On-going
Review quarterly
On-going
4 Implement MRSA action plan to reduce MRSA
bacteraemias
5 Implement C.difficile action plan to reduce number of
C.difficile cases developing in hospital
6 Implement surgical site infection work plan to reduce
the incidence of post operative wound infection
following orthopaedic surgery
7 Undertake review of hospital acquired MSSA
bacteraemias to identify areas for improvement
8 Audit activities
(see separate action plan) CS / BM Sep-11 Mar-12
(see separate action plan) DS / JS Sep-11 Mar-12
Improvement programme led by orthopaedics with
specialist advice and support from infection control
Root cause analysis to be undertaken on hospital
acquired MSSA bacteraemias
All clinical areas to undertake an annual infection
control audit
All clinical areas to undertake regular hand hygiene
audits. Data reviewed at weekly HCAI meeting
All clinical areas to undertake regular audits of
peripheral IV devices. Data reviewed at weekly HCAI
meeting
All clinical areas to undertake regular audits of
commode cleanliness. Data reviewed at weekly HCAI
meeting
Mike
Reed/
IC leads
- TO /
RH
Sep-11
Mar-12
CS Jul-11 Nov-11
ICT /
Ward
manager
s
Ward
manager
s
Ward
manager
s
Ward
manager
s
Sep-11
Apr-11
Apr-11
Apri-11
Mar-12
On-going
On-going
On-going
Undertake audits of policy compliance ICT Sep-11 Mar-12
Page 30 of 33

9 Continue to enhance infection control as an integral part
of clinical governance and patient safety throughout the
organisation. (Board to Ward)
Ensure that all risk registers are regularly reviewed and
updated to ensure that all infection risks are highlighted
BU
governan
ce leads
Jul-11
On-going
10 Provide performance reports to Trust Board Written reports provided to Trust Board on regular
basis. DIPC to attend quarterly.
BM Jul-11 On-going
11 Policy review
Review policies as required as new guidance becomes
available
ICT Jul-11 Mar-11
Review IC29 HIV policy MW Jul-11 Jul-11
Review IC19 Linen policy GH May-11 May-11
Review IC25 GRE policy BM May-11 May-11
Review IC28 Aseptic technique policy RH May-11 May-11
Review IC3 Standard precautions policy CL May-11 May-11
Review and combine IC15 Ice making management
and IC14 ward beverage bay policies
AS May-11 Jul-11
Review IC10 Meningococcal policy JS May-11 Jul-11
Review IC23 Hepatitis C policy MW May-11 May-11
Review IC30 Viral haemorrhagic fever policy DT May-11 May-11
Review IC17 Prevention and management of Dust in
hospital policy
CL May-11 May-11
Review IC18 Ectoparasite policy CS May-11 Jul-11
Review IC31 multi-resistant Gram negative bacteria
policy
Review IC22 Legionella policy
Review IC16 Intravascular device policy
Julie
Samuel
Owen
Cusack
Karen
Connell
y, Liz
Carr, CL
May-11
Jul-11
Sep-11
May-11
Jul-11
Oct-11
Review IC27 Infection control for Pandemic flu policy CL Sep-11 Oct-11
Page 31 of 33

Review IC32 Glove policy DS Sep-11 Oct-11
Review of all other IC policies to ensure cover both
acute and community settings
ICT Sep-11 Nov-11
12 Hand hygiene promotion to staff, patients and visitors A twice yearly display at main entrances – arranged via
ICT and company representatives
13 Education
Page 32 of 33
Deliver sufficient mandatory training sessions to enable
all staff to receive infection prevention and control
training (including hand hygiene) every two years
ICT /
Compan
y reps
Sep-11, Mar-
12
ICT Sep-11 Mar-12
Hold annual infection control study day ICT May-11 Jul-11
14 Communication Ensure that there are robust systems of communication
between infection control and all trust personnel.
15 Cleanliness and Decontamination issues
16 Building works
Embed the use of hydrogen peroxide for enhanced
environmental cleanliness
Review the working patterns of cleaning teams
Liaise with relevant personnel to ensure that building
works / new developments are undertaken in a manner
to minimise infection risks
Ensure NECC plans facilitate good infection control
practices
17 Maintain service provision to external contracts/SLAs Microbiologist support to ICT of Northumberland, Tyne
and Wear NHS Trust
18 Public and patient involvement
19 Links to external bodies
Public/patient/governor representation on MRSA and
C.difficile steering groups
Displays/presentations to Governors if and when
requested
Patient Information leaflets – ensure reviewed as
required
Respond to enquiries from Media through the
Communications department
ICT /
communi
cations
team
V
Gingell
V
Gingell
ICT /
Estates
Paul
Brayson
/ BM
Jul-11
May-11
May-11
Sep-11
Jul-11
Nov-11
Jul-11
Jul-11
On-going
Sep-11
BM Oct-11 On-going
CS to
liaise
Sep-11
On-going
ICT Sep-11 Mar-12
ICT /
Sandra
Guy
BM /
ICT
Sep-11
Sep-11
Mar-12
On-going
Contribute to North of Tyne HCAI group BM / CS Jul-11 On-going
Contribute to North of Tyne Health Protection Group VC Sep-11 On-going

Contribute to SHA Safer Care HCAI taskforce BM Jul-11 On-going
Report infection related SUIs to SHA ICT Jul-11 On-going
BM
GI
CS
VC
DS
JS
ICT
TO
RH
DT
AS
CL
MW
GH
Bryan Marshall
Giles Idle
Catherine Stokoe
Vicky Cleeve
Diane Sisterson
Jayanta Sarma
Infection control team
Tamsin Oswald
Ruth Henein
David Tate
Ania Swann
Cathi Lang
Marian Wilson
Gill Harris
Page 33 of 33