Healthcare Excellence 2010 1


Infection Prevention – it’s everyone’s responsibility!

By Julian Hartley,

Chief Executive,


Infection Prevention is

everyone’s responsibility - that

is the message that UHSM is

driving home to all its staff,

patients, visitors and members

of the public too. We know

that anxiety amongst the public regarding contracting

infections in hospitals is high, and whilst patient safety

is always a priority for UHSM, preventing infections

now has a much higher awareness amongst staff than

ever before following a number of recent initiatives.

Overview of UHSM

University Hospital of South Manchester NHS

Foundation Trust (UHSM) was established as a

Foundation Trust on 1 November 2006. We are a

major acute teaching hospital trust providing services

for adults and children at Wythenshawe Hospital and

Withington Community Hospital. We are recognised

as a centre of clinical excellence and provide district

general hospital services to our local community as

well as specialist services - including cardiology and

cardiothoracic surgery, heart and lung transplantation,

respiratory conditions, burns and plastics, cancer and

breast care services – to the people of South

Manchester and beyond and, in some cases, nationally.

We are recognised in the region and nationally for the

quality of our teaching, research and development. Our

major research programmes focus on cancer, lung

disease, wound management and medical education.

were delighted to achieve compliance against all four

duties set out in the Health Act 2006.

Over the past year, our commitment to reducing

hospital acquired infections has resulted in a

significant reduction in C. difficile Infections and a

reduction in Methicillin Resistant Staphylococcus

Aureus (MRSA) infections. In February 2009, UHSM

was unconditionally registered with the Care Quality

Commission for 2009/10 in respect of its duties in

relation to Infection Prevention.

UHSM was unconditionally registered with the Care

Quality Commission for 2009/10 in respect of its

duties in relation to Infection Prevention.

Through implementation of intensive cleaning,

improved antibiotic prescribing, policy review and

effective isolation, the incidence of Clostridium

Difficile has reduced by 44% from 2007/08 and is 37%

below the target set by the Department of Health.

However for 2008/09, we had 26 cases of MRSA

against a target of 19 cases. In March 2009, the

Department of Health ‘Cleaner Hospital Team’

undertook an audit of observed opportunities for hand

We continue to see reducing Healthcare Associated

Infection (HCAI) as of the highest priority. Our longterm

strategy ‘Towards 2015’, identifies Infection

Prevention as one of the priorities of our safety


Our performance

In November 2008, The Healthcare Commission

visited UHSM for an unannounced inspection of all

issues related to infection prevention and control. We

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hygiene. Overall results showed the need for better

adherence to ‘bare below the elbows’ and better hand

hygiene on entering, exiting and contact with the

patient’s environment.

This lead to us redoubling our efforts to prevent all

healthcare associated infections. Since April this year,

an action plan has been developed to tackle the spread

of infections and we have implemented a wide range

of initiatives which are already showing signs of

success - MRSA rates for Q1 and Q2 of this year are

lower than during the same period last year and C.

difficile rates continue to fall. Here is an overview of

some of the main initiatives we have implemented.

Spread the message, not the infection

The campaign challenged these perceptions by using

photos of a wide range of our staff, from Board

members and clinical directors through to scientists

and clerical staff, demonstrating that all staff, no

matter who they are, are required to help prevent

infections. Using our own staff brought the message

closer to home and demonstrated local ownership and

commitment to infection prevention.

The Infection Prevention – Its Everyone’s

Responsibility campaign has been initially targeted at

staff and uses a very visible poster campaign combined

with electronic messages that automatically appear

each day when staff switch on their PCs, and re-appear

as screensavers throughout the day. A new electronic

message is used each day to keep the campaign fresh,

using a different photo and caption from a member of

staff. The electronic messages are supplemented with a

real-time counter on the screen, informing staff of the

number of cases of MRSA bacteraemia so far and the

number of days since the last one.

In April, we launched a very high-profile

communications campaign called ‘Infection Prevention

– Its Everyone’s Responsibility’ to remind staff of the

need for good hand hygiene. The concept for the

campaign was developed following national research

which showed that barriers to good infection

prevention techniques included lack of leadership and

lack of belief that individual efforts made a difference.

The campaign clearly demonstrates local ownership

and commitment to infection prevention, showing how

it is everyone’s responsibility, from our surgeons to

our maintenance staff, from our cleaners to our nurses,

everyone has to be vigilant. The campaign has been

very high profile, and feedback from staff has been

very positive.

The campaign has been combined with an increase in

the number of alcohol hand gel dispensers around the

hospital and a call for staff to strictly adhere to our

‘bare below the elbows’ dress policy. We have also

increased the number of floor mats at ward entrances

(see photo) and issued all staff with credit card style

aide-memoirs to remind everyone of the importance of

hand hygiene. We have been undertaking weekly hand

hygiene compliance audits and introduced a new

mandatory Infection Prevention seminar for all staff.

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Staff Roadshows

In April, we introduced an additional Infection

Prevention training course which is mandatory for all

staff, clinical and non-clinical alike. The training

consists of a one-hour presentation delivered by one of

the Executive Directors and a member of the Infection

Prevention nursing team. The presentation contains a

reminder of the importance of good hand hygiene and

teaches the seven stage hand washing technique.

Attendance on the course is monitored and all staff are

required to attend the course by the end of September


Our staff, led by our Chief Nurse and Director of

Infection Prevention, invited hospital visitors to place

their hands in an ultra violet light box to see just how

clean they were. Information leaflets and credit card

style aide-memoirs were given out as reminders. The

event was effective in engaging with staff, patients and

visitors to the hospital.

Clinical Engagement

Every member of staff, no matter whether they are

clinical or non-clinical, has also been asked to sign a

declaration or ‘pledge’ to show UHSM is committed to

providing clean, safe care for every patient, with a

policy of ‘zero tolerance’ towards infection.

National Hand Washing Day

On 5 May, UHSM used National Hand Hygiene Day, a

global patient safety initiative hosted by the World

Health Organisation (WHO), to shine a light on

infection prevention.

UHSM has focussed on clinical engagement to help

prevent infections and improve compliance with hand

hygiene. As well as ensuring the support of our

Clinical Directors in our ‘Infection Prevention – Its

Everyone’s Responsibility’ campaign, we have over

the past six months had a big drive to train more staff

in safer techniques such as the Aseptic Non-Touch

Technique (ANTT) for clinical interventions in nursing

teams. This technique helps to minimise the risk of

infection and our aim is to

ensure all front line staff

are trained in ANTT. We

have also introduced new

guidelines to prevent

contamination or infection

during procedures such as

taking blood and giving


Patient Safety WalkRounds were introduced in April

and these consist of weekly visits to clinical areas by

our Executive Team to discuss patient safety issues,

including preventing infections. They are designed to

engage frontline staff on the safety agenda and support

staff in implementation of Trust policies. Following

each visit, the Executive Director provides direct

feedback to the ward or department on areas where

they are doing well, areas of concern or requiring

further attention and relevant updates on Trust-wide

issues including hand hygiene and Infection


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MRSA Screening

In 2008/09 we commenced the screening of elective

patients for MRSA, which means that all patients who

are referred to us for an operation are tested before

they are admitted to see if they may have the MRSA

infection. If they do, they can be treated before they

come into hospital to ensure the risk of cross infection

is minimised.

In addition, we also screen non-elective patients who

are admitted as an emergency ahead of the DH’s

recommendations. A new rapid screening test for

MRSA was introduced at UHSM in August, as part of

our drive to reduce hospital infections. We are the first

NHS Trust in Manchester to introduce the screening

procedure, which means that the results of MRSA tests

are available within just two hours rather than the

previous 24 hour turnaround time. The new process

requires a nasal swab to be taken, which is put

immediately into a medium that comes with the swab,

and fast-tracked to our biochemistry laboratories where

they are processed. A negative or positive result is

available within two hours, with all positive results

phoned through to the ward or department concerned

so that appropriate treatment can commence. By

detecting MRSA early, optimum treatment can start

earlier, and the Trust can also isolate and barrier the

nurse the patient far more quickly to reduce any spread

of infections.

The new swabs will be used for those patients who

come to hospital as emergency admissions, and are

therefore not covered by our elective admission preoperative

MRSA screening.

Microbiology Vitek machine

Earlier this year UHSM took delivery of a new

machine, which our experts say has the ability to not

only correctly identify strains of MRSA, but also

recommend the correct type of antibiotics to treat it.

UHSM Microbiologist Dr Ibrahim Hassan says the

Vitek machine is able to accurately identify a whole

range of HCAIs and provide clinicians with more

accurate results on the type of bacteria, it’s antibiotic

sensitivity and the best type of antibiotic required to

treat them with. Dr Hassan explains: “Samples from

patients are fed into the Vitek machine which analyses

them overnight and automatically loads the results

onto the computer. This gives our clinicians all the

information they need to appropriately treat patients,

which will aid the speed of their recovery. It will also

helps monitor the prevalence of antibiotic resistance

within our Trust and aids the collection of surveillance

data. The £50,000 Vitek Machine was funded by the

Health Protection Agency (HPA) through the

Microbiology Automation Group (MiCAG), which is a

joint initiative between UHSM and the HPA.


When we do see patients with MRSA bloodstream

infections on our wards we ensure we carry out a very

detailed investigation every single time. This is led by

our Medical Director or Chief Nurse to identify the

cause of the infection. Action plans are subsequently

developed or updated to apply the lessons for learning,

feedback to front line staff and reduce the risk of

infections for patients.


Substantial progress was made during 2008/09 to

reduce C. Difficile infections and this was due in large

part to additional cleaning, including the routine use of

chlorine based disinfectants when decontaminating

equipment between use. We have replaced and

upgraded shared equipment such as commodes, and

improved hand washing facilities by installing more

sinks in clinical areas.

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to date, more than 3,000 people have watched a video

of the event on our website and YouTube.

2009/10 Performance

With the implementation of the above plan, UHSM has

seen a 40% reduction of our hospital acquired MRSA

bacteraemias in the last year and we have now met our

PCT contract for two consecutive quarters of the year.

For C. difficile, we have reduced our rates

dramatically, by 73% compared to last year.

A common cause of C. difficile is the incorrect use of

antibiotics and we have developed clear guidelines for

the use of antibiotics and, through training, education

and regular audit, ensure that our doctors

and nurses adhere to these.

Wider Engagement

Our Infection Prevention – It’s Everyone’s

Responsibility campaign, which focuses on the need

for all everyone to take personal responsibility for safe

and clean care, has been widened to encourage wider

support from our patients, members and local


In July, we hosted our ‘Great Hospital Hand Wash’

event at which around 1,000 people gathered outside

the main entrance of the hospital and participated in

the UK’s largest mass handwash technique training.

The fun event – set to music with lyrics highlighting

the seven stages of effective hand washing – attracted

media local attention for the handwash campaign and,

The huge reduction in infections acquired in our

hospital is testimony to the renewed effort lead by the

Executive Team at UHSM that has clearly engaged our


Future Work

The next phase of the Infection Prevention – It’s

Everyone’s Responsibility campaign will be to extend

it to our local community via links with local schools.

Later this year we will be taking our Great Hospital

Hand Wash music, lyrics and video out to local

primary schools to teach young children about the

importance of good hand washing.

There are plans to continue to engage with clinicians at

all levels, and a new ‘Beat It’ campaign planned to

target clinical and nursing staff in particular about

preventing hospital acquired infections.

Work on training, improving handwashing facilities

and awareness will continue, and this year, we hope to

truly beat HCAIs by all working together.

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