1. Infection Prevention and Control in Commissioning Josie McHale-Owen

2. Infection Prevention IPCN – Countywide hosted by SWCCG -1 st July 2013 & H&C Trust contract is maintained. Our aim - Deliver a culture of continuous improvement  A whole systems approach – clear structures roles and responsibilities  Ensure staff compliance with best practice  Provide a safe and appropriate environment that facilitates the prevention and control of infections  Work collaboratively with all agencies to ensure seamless care.

3. Our Expectations Countywide Health and Social care vision for improving IPC and reducing risk of HCAI’s in all areas of health and social care Worcestershire. Shared learning from incidents and surveillance. Post Infection Review (PIR) of MRSA Blood Stream infections (MRSA BSI) and Clostridium difficile (CDI) Working with Public Health England (PHE), acute and community providers, primary care, residential and nursing homes and social care and the public. Surgical site surveillance to include post discharge to ensure accurate data on procedures perceived to have increased risk if infection. Improved environmental cleanliness. Zero tolerance of avoidable infections. Patient Focused

4. So Far… Health Economy Strategy to be launched July 2014. MRSA – Post infection review (PIR) on all cases – 2013/14. CDI – All CCG’s and providers were able to meet targets for 2013/14, challenging targets for 14/15 requiring a detailed review of individual cases to identify cause and share learning. Enhanced surgical site surveillance – caesarean sections and large bowel surgery – commenced April Hydration project – HE initiative – to include public awareness and social care. All care home assurance visits include IPC and environmental cleanliness

5. Winter Plan Improved communication and strong communication cascade with H&CT and WHAT. Outbreak Information shared across health and social care and neighbouring counties. Outbreaks in residential and care homes - led by PHE and supported by CCG –daily contact Monday-Friday to offer practical support. Updates of areas affected issued daily to provider organisations to enable high risk patients to be identified promptly. (Infection risk stickers introduced). ‘Stay Hydrated – Stay Healthy’ campaign – Countywide June 2014 – prevent admissions and illness due to affects of dehydration. Enhanced training for care home staff – outbreak management, infection prevention – the basics and importance of hydration. D&V pathway. Patient and resident information leaflet Information and links on CCG home pages.

6. That was then this is now ! Provider2012/132013/14 South Worcestershire CCG N/A 8962<30% Redditch & Bromsgrove CCG N/A 4239<9% Wyre Forest CCG N/A 3621<42% NHS Worcestershire (Sum of 3 CCGs) 176 215 >22% 167 121 <27% March data included but not confirmed <27% Worcestershire Acute Hospitals Trust 52 80 >53% 48 40 <20% Worcestershire Health and Care Trust 12 9 <25% 10 5 < 50% Trajectory CDI reportedCDI Reported Against Trajectory

7. Reducing CDI Nationally a reduction in infections of more than 90% since 2007 …but it should never have been so high! Guidance ‘Clostridium difficile infection’ – how to deal with the problem ….2009 revised 2012 Reducing the incidence of CDI was never rocket science…. Hand washing with soap and water ! Recognition of infection – prompt diagnostics and treatment. Isolation Hydration and fluid balance Environmental Cleaning Antibiotic stewardship But are we now at the irreducible low levels? 2013/14 – all CCG’s, Acute Trust and Health & Care Trust met their targets.

8. Rates of CDI in Worcestershire – 2007-2013

9. MRSA BSI Zero tolerance – 8 incidents investigated in Worcestershire 3 – Apportioned to Worcester Acute – (2 contaminates) 1- Pre 48 hour WFCCG – April 2013 1 – Pre 48 hour RBCCG – January 2014 1 – Pre 48 SWCCG – September 2013 1 - HEFT 1 - Gloucestershire Acute.

10. MRSA in Worcestershire

11. 10 criteria – 9 Apply to Primary Care

12. Feedback from recent CQC IPC reviews in Primary Care Wanted evidence of recent IPC audits CQC inspector reported that the practice did not have a DIPC – the guidance for Primary Care states that a DIPC is not required in Primary Care – but you do need a designated lead Inspectors were very pleasant, but spent a lot of time checking dates on sterile items in clinical room If recommendations made by previous audits by IPCN’s were not implemented it was noted as ‘noncompliant – even when the recommendations said ‘in the event of refurbishment ….’ The guidance for primary care states ‘Annual IP statement’ – CQC expected one. Hand hygiene audits – required evidence a simple compliance tool and practical hand hygiene education may help support you. Policies – if you use someone else’s make sure they are personalised to the practice – ‘it was noted that the practice were using another PCT’s policy document but there is no statement to reflect that the practice had assessed the guidance/policy as safe to use in their environment’. Governance structure was criticised – if action plan agreed you must named leads, give realistic timescales and provide evidence of review. Document an exception report if plans change, be able to provide evidence of discussion in practice meetings. Neighbouring CCG is advising their practices to put in place an annual programme of work for IPC – to include audits schedule, training and surveillance, the progress is reported via the practice meetings and IPC is a regular agenda item. PAT testing and maintenance of equipment. Cleaning schedules of equipment – clinical equipment ensure instruction for decontamination is written down and is evidenced back to the manufacturers guidance. COLD CHAIN – Audit has been issued please complete and return to Carole Clive – keep a copy as your evidence and ensure any actions identified are implemented - review at least annually.

13. . Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them Designated person to lead on IPC Infection control programme – IPC measures needed in the practice Policies procedures and guidance – how are they monitored and regularly reviewed and dated Training – induction and on-going attendance – on line / face to face / in house/ related training Record of names and contact details of health practitioners who can provide advice. Annual statement – infection incidents, audits risk assessments training and policy reviews

14. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections Designated lead for cleaning and decontamination Premises to be furnished taking into account national guidance and rooms with specialist functions Environmental cleaning policy should specify how to clean all areas fixtures and fittings – and specify what products to use. A specific cleaning specification for minor ops rooms.

15. Provide suitable accurate information on infections to service users and their visitors Information about your approach to prevention and control of infection, staffs roles and responsibilities and who people should contact with concerns about infection prevention and control of infection. Have available up to date information on current infections such as influenza/norovirus/ new vaccinations

16. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/ medical care in a timely fashion. Primary medical care practitioners are key providers of information to other health and social care providers and to public authorities, both concerning individual users and community outbreaks.

17. 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 The primary medical care practitioner will provide initial advice and treatment when a patient in their care develops an infection and will assess any potential communicable disease control issues. In most cases further action will not be required however if required the primary medical care practitioner may consult with IPC advisor or PHE or refer to specialist care (TB.

18. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection. Ensure that every person working in the practice including agency staff external contractors and volunteers understand the need to prevent and control infections and know their responsibilities.

19. Secure adequate access to laboratory support as appropriate Access to diagnostics microbiology and virology laboratory's service which operates according to the requirements of relevant national accreditation bodies.

20. Have and adhere to policies, designed for the individual’s care and provider organisations, that will help to prevent and control infections. Policies are listed and assurance criteria – including Standard Infection Prevention and Control precautions, aseptic technique – see table in the document.

21. 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. Provide access to occupational health services or similar

22. What now ……. Easy wins – Education and training Ultra violet light box - practical Environmental Audit -keep it simple Health and Care Trust provides audit tools Keep in an evidence folder make it accessible Decontamination guidance – follow manufacturers guidance.

23. Comment issued by QCQ following inspections - Outcome 8 – Cleanliness and infection control. They did not have appropriate systems in place to prevent the spread of infection or they did not maintain an appropriate level of cleanliness. For example, these practices had not carried out risk assessments and did not have plans in place to prevent, detect and control the spread of an infection. We recognise that risk assessments and plans will be different to those in secondary care but they are still an essential part of infection control practice. In some cases we saw practices were not as clean and as hygienic as would be expected and there was no evidence of appropriate cleaning procedures or schedules to ensure that the practices were kept clean.

24. Back to basics …Standard Infection Prevention and Control precautions Hand Hygiene - Access to sink/ soap /towels Use of Gel Technique Cover cuts and breaks Bare below the elbow Practical training

25. PPE Gloves Aprons Face masks Eye Protection Single use symbol

26. Sharps & Needle stick Injury Sharps boxes No more than 2/3’s full Label and date Temporary closure Never re sheath sharps European Sharps Safety Framework Transporting sharps boxes

27. Management of Sharps Injury 1.Force bleed under running water 2.Wash and dry 3.Apply waterproof dressing 4.Report 5.Ensure guidance and advice is readily available within the practice

28. Waste Ensure staff know what waste streams are used for. Storage is locked but accessible Waste contractor provides service to meet your needs and meet the contract Foot operated lidded bins Bins and storage are clean and on cleaning schedule Audit – can be simple

29. Decontamination Where? How? Who? Medicines and Healthcare Products Regulatory Agency (MHRA) “Follow the Manufacturers Guidance”

30. Spills Who and how – training? Equipment –spill kits PPE Disinfectants Environment Disposal

31. Specimens Policy Training Standard Operational Procedure PPE. Hand washing Storage

32. Occupational Health Common Infections – exclusion criteria Vaccinations – influenza / Measles/Hep B Skin conditions Resistant organisms Use the HPU website – excellent information for patients and HCW

33. Questions ?