Control of infection –
25 February 2004
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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,
•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.
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
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 this.by 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
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 happen.management 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 implemented.services.A 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
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.
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.
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:
•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.
Bristol North PCT
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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 basis•The Medical Devices sub-group will report to the ICC on a quarterly basis•The 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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INFECTION CONTROL RISKS AND WORKPLAN 2003 / 04REFSTANDARDRISK DESCRIPTIONACTION DESCRIPTION PCTLeadSTART REVIEW Comment
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.
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
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
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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