Appendix 2

By Dorothy Ferguson,2014-03-26 16:05
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using the controls assurance standard as a framework. Core programme to be produced by Avon wide infection control group, EMc, 1/04/04, 31/3/05

Control of infection –

    Annual Report

    25 February 2004

    If you need this document in a different format please telephone Sam Otorepec on 0117 900 2662


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1Purpose and overview

    This document reviews the control of infection function of the PCT, using the controls assurance

    standard as a framework. It describes the processes and structures that have been set up in the

    past 12 months and describes the work that remains to be done


    The PCT has broad responsibilities relating to communicable diseases and control of infection,

    these include:

    Communicable disease control – control of infectious diseases in their natural settings

    such as within families, schools and wider community

    Infection control – control of infections that arise in care settings such as hospitals,

    nursing homes and general practice

    Decontamination – ensuring that re-usable medical devices are properly decontaminated

    Immunisation – coordinating and implementing national and local policy, ensuring high

    uptake rates and commissioning immunisation for specific groups

    Commissioning secondary care services - including infection control services that protect

    patients from hospital acquired infectionThis report concentrates on infection control and its associated controls assurance standard.

    Decontamination and some aspects of communicable disease control are included either

    because they are inextricably linked (decontamination) or are included in the controls assurance


    3Infection control – a priority

    Infections acquired as a consequence of health care (“Health care associated infections”) cause

    major morbidity and may cause death. Around 9% of hospital in-patients acquire an infection

    while in hospital and around 5,000 deaths each year might be primarily attributable to health care

    associated infection and in a further 15,000 cases it might be a substantial contributor. Although

    many infections transmitted to patients during their care occur in hospitals, more care and

    procedures associated with it now take place in a primary care setting. Between 50 and 70% of

    surgical wound infections occur after discharge from hospital.

    The problem of infection control seems to be getting worse over the last three decades rather

    than better. A recent report from the Chief Medical officer highlighted the following factors as

    playing a part in this increase:

    Many more seriously ill patients who are more susceptible to infection (because of

    immunosuppression or general age or frailty)

    A growth in invasive procedures and diagnostic tests which increases the likelihood of infection being introduced

    Mixing of patient populations as hospitals take in from wider catchment areas and pressure on beds leads to higher levels of in-hospital patient movements and discharge into the community

    The growth of antimicrobial resistant organisms


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Weaker standards of cleanliness and hygiene

    A lack of awareness of, and senior management attention given to infection control procedures

     All NHS organisations are required to put infection control and basic hygiene at the heart of good

    management and to ensure that appropriate resources are allocated to provide effective

    protection of the public’s health (with particular regard to the prevention of health care-acquired

    infection, communicable disease and antibiotic resistance).

    4Scope of services and recent history

    The PCTs responsibilities for control of infection embrace services provided by

    Directly employed staff, including community nursing, therapies and podiatry

    Independent contractors, including general medical practice, dentistry, and optometrists

    The PCT brings together staff and services from three main organisations, most pertinently a

    large community workforce from North Bristol Trust (NBT) and UBHT, and staff from the former

    Health Authority, including a Public Health Directorate and primary care commissioners. The

    community staff depended on training and expertise within the acute setting and Health Authority

    staff relied on advice and guidance from the Avon Health Protection Unit. Expertise in control of

    infection did not transfer with community or health authority staff and so an early priority for the

    PCT has been setting up its own structures, developing capacity and maintaining or developing a

    network of expertise across Avon.

    5Controls assurance standards

    The controls assurance standard for Infection control has been written for the hospital

    environment but are described as broadly applicable to all PCTs. The 15 criteria are listed in the

    table below, together with a description of how well the PCT meets each criterion and steps

    needed to achieve relevant compliance.

    CriterionPCT compliance

    1. Board level responsibility for Nurse Director has overall Board level infection control is clearly defined and responsibility. The newly appointed Infection there are clear lines of accountability Control Nurse is responsible for all service delivery for infection control matters aspects of infection control and decontamination. throughout the organisation, leading (Organisation chart – Appendix 1)to the Board.

    2. There is an Infection Control BN & SGlos PCT’s will have one Infection Control Committee which is directly Committee (Terms of Reference attached – accountable to the Chief Executive Appendix 2). This will report into the PCT Risk and Trust Board that endorses all Management Committee.infection control policies, procedures,

    and guidance, provides advice and

    support on the implementation of

    policies, and monitors the progress of

    the annual infection control


    3. There is an appropriately It is not realistic for each PCT to have a full constituted and functioning Infection infection control team. Possible solutions Control Team, includingare being explored, either by calling on The infection control doctor(s) specialist advice within NBT, agreed as an /convert/tmp/12202962/12202962.doc

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    (ICD)SLA, or by forming a pan PCT Infection The infection control nurse(s) Control team.


    A consultant medical

    microbiologist if the ICD is from

    another specialty

    4. Prevention and control of infection This currently does not happen. A PCT policy will is considered as part of all service be developed to include this.development activity.

    5. An organisation wide annual The newly appointed Infection Control Nurse is a infection control programme with joint appointment with SGlos PCT. They will be clearly defined objectives is produced responsible for co-ordinating the Infection Control Team.

    6. Written policies, procedures and Different staff groups, both in community and guidance for the prevention and primary care, have inherited different policies and control of infection are implemented guidance. A single community set of policies and and reflect relevant legislation and procedures for primary care and community staff published professional guidance.has been produced with the help of Avon Health

    Protection Agency, and will be implemented shortly7. There is an annual programme for There is currently no programme for the audit of the audit of infection control policies infection control procedures. This will be part of the and procedures.Infection Control Nurse role to co-ordinate. A

    clinical governance questionnaire was undertaken

    with all GP Practices and HMP Bristol, which did

    provide a higher level baseline of information.8. Timely and effective specialist In practice this is happening, both to local PCT staff microbiological support is provided and to Avon Health Protection Agency. The service for the infection control service.from NBT has been formalised in a draft SLA.9. Surveillance of infection is carried Some systematic surveillance in place but no formal out using defined methods in reporting from health protection staff. Memorandum accordance with agreed objectives of understanding between HPA and PCT not yet and priorities, which have been finalised. specified in the annual infection

    control programme.

    10. A comprehensive infection control This baseline review is the first annual report, to be report is produced by the Infection improved on once audit and surveillance are better Control Team on an annual basis, established. and is presented to the Board.

    11. The Infection Control Committee This happens through advice from HPA staff and a and Infection Control Team have Memorandum of understanding between HPA and access to up-to-date legislation and PCT.guidance relevant to infection control.

    12. Education in infection control is This is not happening. Simple training on hand provided to all health care staff, washing has not occurred recently or in a structured including those employed in support way. The new Infection Control Nurse will help set services.up locality based link nurses to receive and cascade

    training and conduct training needs assessment,

    ensuring a systematic approach is taken.13. Key indicators capable of Well established surveillance of infectious diseases showing improvements in infection and immunisation rates in place. No evidence of control and/or providing early warning usage at all levels.of risk are used at all levels of the

    organisation, including the Board,

    and the efficacy and usefulness of

    the indicators is reviewed regularly.

    14. The system in place for infection This baseline review and subsequent Annual


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    control is monitored and reviewed by programme and reports will allow that to and the Board in order

    to make improvements to the system.

    15. The Board seeks independent The PCTs in former Avon have compared systems assurance that an appropriate and put in place for infection control, through the DPH effective system of managing group. The Risk Management Committee will infection control is in place and that advise whether further independent assurance is the necessary level of controls and needed for a PCT that does not provide hospital monitoring are being workplan (Appendix 3) based on a similar analysis, with timescales and responsibilities, was

    drawn up and is being reviewed as part of the risk management process within the PCT.

    6Infrastructure and priorities for development

    There is currently minimal Infection Control infrastructure within the PCT. The Risk Management

    Committee identified two developments as a priority.

    1.Securing funding and appointing an Infection Control Nurse.

    (This has now been done and Liz Mc Loughlin is a G Grade nurse, shared between

    BNPCT and SGlos PCT. She started in post on 2 February 2004). The advantages of a

    joint post are that this will encourage joint policy development and a consistent approach

    to infection control practice.

    This is the minimum resource that is needed and will need annual review with the

    likelihood of more resource needed in the future.

    Once the Infection Control Nurse has settled into post, it is envisaged that the Link Nurse/

    Cascade system will be established with both community staff and staff based in GP

    Practices, Prison, Dental Surgeries and Optometrists.

    2.Strengthening links with NBT

    The Infection Control Committee will oversee the work plan and ensure that links with

    NBT, through the SLA, are strengthened. These links include the provision of Specialist

    advice, Clinical Supervision from the Consultant Nurse, Infection Control and access to

    the up to date, enhanced based practice. Similar links are needed with the Health

    Protection Unit.


    Decontamination is the combination of processes (including cleaning, disinfection and

    sterilization) used to render a reusable item safe for further use on patients and handling by staff.

    The effective decontamination of reusable surgical instruments is essential in minimising the risk

    of transmission of infectious agents. Controls Assurance standards exist for the related issues of

    decontamination, the management of surgical instruments and associated equipment, and

    infection control. Organisations are legally required to undertake assessments and complete their

    returns as part of their risk management system.

    It is important that systems are in place to allow sets of surgical instruments to be tracked

    through decontamination processes in order to ensure that the processes are effective. Systems


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    should also be in place to enable the identification of patients on whom the instrument sets have been used (traceability). This is important so that the relevant patients can be identified in the event of exposure to potential risk. This is relevant to both the primary and secondary care sectors.

    Currently, within community Health Centres, clinics and GP surgeries, Bench Top Sterilisers are used to sterilise instruments prior to patient use. New regulations mean that full compliance using these is difficult and extremely time consuming. It is probable that the best solution involves sending all re-usable instruments to a central sterile services department (CSSD), this would also allow a traceable path from the sterilisation process to the patient.

    The move toward using CSSD will carry additional cost. Further work is needed on costing, in particular to compare the cost of a move to CSSD with renewing and replacing existing equipment.

    At present the PCT is not fully compliant with recommended decontamination procedures and so a multi-disciplinary Decontamination sub-group will be set up across BN & SGlos PCT’s to risk assess current working practices and present options for full compliance, with costs and risks of each option. This group will report to the Infection Control Committee.

    Medical Devices

    The term ‘medical device’ covers all products, except medicines, used in healthcare for the diagnosis, prevention, monitoring or treatment of illness or handicap. The range of products is very wide: it includes contact lenses and condoms; heart valves and hospital beds; resuscitators and radiotherapy machines; surgical instruments and syringes; wheelchairs and walking frames – many thousands of items used to each and every day by healthcare providers and patients.There is a specific Controls Assurance Standard covering the use and safety of medical devices. There are however links between control of Infection and it is envisaged that the Infection Control Nurse will play a key role in ensuring compliance with the standard.

    The PCT is setting up a Medical Devices Group which will link into the Risk Management Committee.

    Communicable diseases

    Appendix 4 (a) & (b) show the statistics of diseases notified to the Health Protection Unit for 2002 and 2003. For the purposes of this report, the 2002 figures include both Bristol North and Bristol South & West PCT’s. For 2003 and future reports, we have PCT specific information.Summary of Cryptosporidium Outbreak across Avon: August – November 2003

    This report details the investigation of an outbreak of cryptosporidium in the Avon region of the South West of England. The investigation was carried out during the months of August – November 2003 by the outbreak control team.

    Cryptosporidium is a protozoan parasite and a leading cause of infectious diarrhoea in humans and cattle. Transmission occurs through animal-to-human or human-to-human contact, by recreational exposure to contaminated water or land, or by consumption of contaminated water and food. There are few effective control measures. For example, within recreational water facilities, cryptosporidium parasites can only ever be limited by chlorine disinfection and filteration.

    The peak of the outbreak in Avon (August – November) mirrored that of the national peak in the United Kingdom and the number of cases reported during the outbreak were the highest compared with recent years. Results of environmental health samples sent for laboratory testing /convert/tmp/12202962/12202962.doc

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    implicated 8 recreational water facilities within Avon. Despite a number of cases having visited sites abroad and in the United Kingdom where cryptosporidiosis outbreaks had been reported, only one case had visited a local pool where cryptosporidium occysts were subsequently found. However, it is inconclusive that this case could have been the source of infection. No point sources of infection could be identified among the recreational water facilities but they may have acted as sources of transmission. This was similarly the case when looking at contact with zoo/farm animals. No point source of infection could be identified of the sites most visited and only a few cases has also visited local swimming pools with onset of symptoms occurring throughout September and October when most of the control measures among the recreational water facilities have been implemented. Nor could any potential infection from water or unpasturised milk be indentified of cryptosporidiosis within the two nurseries.The control measures implemented varied but concentrated on limiting the transmission of infection by:

    Cleaning up or closing down recreational water facilities known to have cryptosporidium


    Public health measures of notifying the public and other heath professionals.

    Environmental Health Officers providing advice on improving hygiene practices within


    The conclusion drawn from this outbreak are that it may have been travel related but this is unlikely and that transmission was through a number of recreational water facilities. These findings are in keeping from similar experiences in Leicester, Exeter and Coventry where other large outbreaks of cryptosporidium had also occurred during the same time period.Hepatitis B

    This is an ongoing outbreak and well publicised.

    Future developments in Infection Control

    There is much work to be done to improve standards of Infection Control within Primary Care. This resolves around:


    working practices

    education and training

    equipmentThis baseline report for 2003 – 2004 demonstrates that there has been progress and there is clarity around accountability, structure and support and a work plan with identified leads to progress and that the PCT is committed to improving Infection Control Standards, investing to facilitate this.

    Alison Moon

    Nurse Director

    Bristol North PCT


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    Appendix 2

    Terms of Reference

    To develop and implement policies to meet the infection control standard within

    the national controls assurance (NCA) framework

    To specifically address the requirements of criterion 2 of the NCA

    There is an Infection Control Committee whis is directly accountable to the Chief

    Executive and Trust Board that endorses all infection control policies procedures

    and guidance provides advice and suppot on the implementation of policies and

    monitors the progress of the annual infection control progarmme”The Infection Control Committee (ICC) will report to the PCT Risk Management

    Committee through an annual report and circulation of the minutes to the Chair of

    the Risk Management Committee. The Nurse Director also sits on the Risk

    Management Committee and can provide it with periodic verbal and written

    reports/updates on ICC matters as required

    Through the Nurse Director the Clinical Excellence Committee can receive written

    and verbal repots/updates as requested

    The decontamination sub-group will report to the ICC on a quarterly basisThe Medical Devices sub-group will report to the ICC on a quarterly basisThe ICC will receive reports on infectious disease survellance from the Avon Area

    Health Protection Unit of the Health Protection Agency

    The PCT ICC will be represented on the advisory Avon ICC by the Director of

    Public Health and Nurse Director


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    Appendix 3


    DATEDATE2INNo infection control Infection Control Committee AM1/04/0431/3/05

    programmewill oversee production of

    policy, report and programme

    3INInfection control team Service level agreement with AM1/04/0431/3/05Now proposed

    function located within NBT will be written and to be BNSSG

    NBT, not PCTagreedwide

    4INPrevention and control of PCT policy on control of AM/EMc1/04/0431/3/05

    infection is not formally infection will be developed to

    considered as part of all include this.

    service development


    5INNo infection control Core programme to be EMc1/04/0431/3/05

    programme produced by produced by Avon wide

    the Infection Control infection control group


    6INNo uniform set of Uniform set of policies and AM/EMc1/04/0431/3/05

    policies, procedures and guidance to be produced

    guidance implemented

    7INIndividual audit activity, A programme of COI audits Emc/LF1/04/0431/3/05

    not co-ordinatedfor primary care and directly

    employed staff will be


    8INNo secure SLA for timely SLA between NBT and PCT AM 1/04/0331/3/04Now proposed

    and effective specialist to be agreedto be BNSSG

    microbiological supportwide

    9INSome systematic Memorandum of 1/4/031/10/03

    surveillance in place but understanding between HPA

    no formal reporting from and PCT needs finalising.

    health protection staff

    10INNo comprehensive Produce infection control AM1/04/0331/3/04

    infection control report is report with contribution from

    produced by the Health Protection Agency

    Infection Control Team


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    11INCurrent good liaison with Memorandum of AM1/4/031/10/03

    Health Protection unit understanding between HPA

    needs securingand PCT needs finalising.

    12INEducation strategy not Appoint locality based link EMc1/04/0431/3/05

    yet fully implementednurses to receive and

    cascade training, conduct

    training needs assessment

    13INKey indicators capable Include COI as part of AM1/4/0331/3/04

    of showing controls assurance

    improvements in mechanism and reported to

    infection control and/or the board via the Risk

    providing early warning Management Committee

    of risk are not used at all

    levels of the organisation

    14INAnnual programme and Annual programme and AM1/04/0331/3/04

    report not yet presented report presented to the board

    to the board

    15INThe Board has not To seek independent AM1/04/0331/3/04

    sought independent reviewer, as advised by Risk

    assurance that an Management Committee

    appropriate and effective

    system of managing

    infection control is in

    place and that the

    necessary level of

    controls and monitoring

    are being implemented.


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