Incidence of healthcare assoc
Infection Prevention and Control
Joanne Flanagan, Infection Prevention and Control Nurse Specialist (CNS)
TABLE OF CONTENTS
Infection prevention and control committee
Infection prevention and control policies, procedures and guidelines
Meticillin resistant staphlococcus aureus
Meticillin resistant staphlococcus aureus
Meticillin sensitive staphlococcus aureus
(MSSA) blood stream infection
Extended spectrum Beta- Lactamase (ESBL)
Carbapenem- resistatn Enterobacteriaceae
The term “Healthcare Associated Infections” (HCAI) encompasses any infection
by an infectious agent acquired as a consequence of a person’s treatment or is
acquired by a healthcare worker in the course of their duties.
The Health Information and Quality Authority (HIQA) is an independent Authority
which was established under the Health Act 2007 to drive continuous improvement in
Ireland’s health services. In May 2009 HIQA launched The National Standards for the
Prevention and Control of Healthcare Associated Infections. These 12 standards are a
key component in maximising patient safety and improving quality of care. Blackrock
Clinic also is accredited by Joint Commissioner International (JCI).
The Infection Prevention and Control (IP&C) Annual Report provides an opportunity
to highlight the infection prevention and control activities that have been put in place
The prevention and control of infection is taken very seriously in Blackrock Clinic. A
programme of activities to embrace national initiatives and to reduce infection rates
has been developed and implemented. The activities which contribute to infection
prevention and control are provided by all departments within the hospital. Infection
prevention and control is the responsibility of all healthcare workers and is included
into everyday practice. The objective is to engage staff at all levels in order to
maintain a culture that supports infection prevention and control practices across the
The IP&C programme has a multi-faceted role in preventing the transmission of
disease, which includes surveillance of healthcare associated infections, resistant
organisms and the prevention of infection and control of existing infection.
INFECTION PREVENTION AND CONTROL STRUCTURES
Infection Prevention and Control Committee
The Hospital Chief Executive Officer is responsible for the prevention and control of
The Infection Prevention and Control Committee (IPCC) is chaired by the Matron
(Director of Nursing) and the CEO sits on the committee. The committee is
responsible for providing an infection control strategy in Blackrock Clinic. The IP&C
committee analysed surveillance figures, infection control audits, outbreak reports and
also ratified all updated and new Infection Prevention and Control policies,
procedures and guidelines throughout 2011.
Membership of the Infection Prevention and Control Committee 2011
Dr. Lynda Fenelon Consultant Microbiologist
Dr. Kirsten Schaffer Consultant Microbiologist
Cardiothoracic Clinical Nurse Specialist
Mary O’Gorman Theatre Clinical Nurse Specialist Susan O’ Doherty General Surgical Clinical Nurse Facilitator
Claire Hogan Orthopaedic Clinical Nurse Specialist
Derek Nealon/ Michael McGowan Engineering Manager and Facilities Manager
The Infection Prevention and Control Team is accountable to the Infection Prevention
and Control Committee (IP&CC). The team includes the IP&C Nurse Specialist and
the Consultant Microbiologist. The IP&CT continues to provide operational direction
and advice to clinical and non clinical staff within the Hospital. The IP&CT is
supported by the microbiology laboratory.
INFECTION PREVENTION AND CONTROL POLICIES, PROCEDURES AND GUIDELINES
There are currently 42 Infection control policies, procedures or guidelines available
on Q Pulse. The IP&CT has a programme for revision of infection control guidelines
as per hospital policy. The Infection Control Programme is available on Q Pulse for
EDUCATION AND TRAINING
Education is a key component in reducing avoidable infection. All new staff starting
in the hospital receive Hand Hygiene education as part of their orientation
programme. Nursing staff receive a more extensive orientation where the IPCN signs
each nurse off on their competencies. In 2011, 128 staff attended the Orientation
Existing clinical staff receives regular education sessions which focus on specific
topics, relating to infection prevention and control. This may be on a new product or
updated changes on an existing policy. Other education sessions are delivered in
addition and include informal ward based sessions, telephone advice, information
leaflets and posters. Verbal feedback from staff, patients and visitors is always
positive. Alongside the Infection Prevention and Control Nurse, the CNS in each
specialty has assisted in staff education in relation to infection control throughout
There has been a clear focus on Hand Hygiene education and awareness throughout
the hospital in 2011. No hand jewellery, apart from a wedding band may be worn by
clinical staff. Hand Hygiene education stands were set up at hospital and clinic
reception areas to display hand gel and information leaflets for staff and visitors.
Blackrock Clinic closely monitors the World Health Organisations (WHO) Hand
Hygiene Campaign. In May 2010, all health-care facilities registered for the
WHO SAVE LIVES: Clean Your Hands
annual campaigns were invited to
participate in a global survey in May, by observing hand hygiene compliance.
Making tasks systematic is also a proven way of achieving quality. The ' My 5
Moments for Hand Hygiene'
approach defines the key moments when health-care
workers should perform hand hygiene. This evidence-based, user-centred approach is
designed to be easy to learn, logical and applicable in a wide range of settings. In
2010, the WHO Clean Care team intensified its focus on providing training sessions
that promote the practical implementation of WHO 'My 5 Moments for Hand
Hygiene' approach. Blackrock Clinic followed this in the education sessions
The introduction of the HPSC audit tool in 2009 has proven a breakthrough as all
healthcare facilities in Ireland will measure compliance using the same standard. The
Audits were carried out by the IP&C nurse specialist and dedicated managers that are
on house duty. These staff member were trained to use the new national audit tool to
carry out their audits. The audit result target was reviewed by the IP&CC in 2011.
The National compliance target for the HSE is 75% so we decided to aim for the same
compliance rate in Blackrock Clinic, see figure 1.
Work is constantly ongoing to raise
this percentage. There were 25 education sessions that focused on Hand Hygiene in
2011, see figure 1.1
. The attendance rate for hand hygiene education was 60% in
2011. We aim to improve on this in 2012 by training more educators, such as the
clinic nurse specialist team. The accommodation staff had poor attendance in 2011.
We aim to improve this in 2012 by providing group education at a time that is
convenient for all staff, within the clinical setting.
The ultimate target that we aim for in BRC is 100% compliance with Hand Hygiene.
One ward did not achieve the pass rate on the first audit so we provided education and
re audited within 4 weeks. There was no evidence of an upward trend of infection in
Hand Hygiene Compliance in BRC in 2011 is 86%
National compliance rate in 2011 is 74.7%
ward ward ward ward ward ward ward ward ward ward
Figure 1 Compliance with Hand Hygiene in Blackrock Clinic is 86% in 2011
Hand Hygiene Education attendence attendance rate for Blackrock Clinic is 60% in 2011
(361/ 603 staff edcuated- This does not include Orientation)
Figure 1.1 The hand hygiene Attendance results in Blackrock Clinic
Monthly environmental audits were carried out by the accommodation manager and
reported back to the Hygiene Committee. This data will be used by the wards and
departments for actions to improve performance. The hygiene committee continues to
meet every Tuesday to communicate to staff and implement best practice.
Many other audits were carried out in relation to Infection prevention and control. If
the audit is failed, education is put in place. A repeat audit is carried out within 4
weeks of original audit. See figure 2.
Audit results in 2011
Average Infection control audit result is 90%
bulance o le
Figure 2 The average audit result when measured with the infection prevention and
Regular surveillance is carried out on the incidence of infections among inpatients on
a quarterly basis. The Microbiology department in the hospital telephone/ bleep the
Infection control nurse with any new alert organisms e.g. MRSA, Clostridium
A critical function of Infection prevention and control is Surveillance of Infections.
The objective of surveillance is to provide rates of healthcare associated infections
(HCAI) in Blackrock Clinic. This allows the Infection prevention and control team to
recognise trends in infection and carry out audits or implement education. After
discussion with the specialist team the need for change may be implemented where
SURGICAL SITE INFECTION SURVEILLANCE
Surgical site infections (SSI) are identified by development of infection at the site of
surgery within 30 days of surgery. These SSI’s are broken down into categories ie
Superficial, Deep and Organ space SSI. All wounds that breakdown are reported to
the Infection control nurse. Records of these are kept and they are discussed on a
weekly basis with the Microbiologist. This allows us to look at trends and carry out
further SSI surveillance on other patient groups, where necessary.
Cardiac Surgery SSI Surveillance
The overall Cardiac surgery SSI infection rates have reduced from 2009. Many
interventions have been put in place to achieve this reduction. There is a Cardiac
surgery team meting every Friday on William stokes unit. At these meeting each
patient is discussed. Some of the new interventions introduced were the introduction
of silicone dressings (to avoid blistering caused by adhesives) and sternal binders as a
prophylactic measure in reducing sternal dehiscence for at risk patients. See figure 3
Surgical Site Infection (SSI) rate in Cardiac Surgery from 2009 - 2011
a sa I 3.00%
Overall SSI rate
Figure 3 Surgical Site Infection (SSI) rates in Cardiac Surgery from 2009 - 2011
Orthopaedic surgery SSI Surveillance
Orthopaedic Surgical site infections (SSI) are identified by development of infection
at the site of surgery within 30 days of surgery. These SSI’s are broken down into
categories ie Superficial, Deep and Organ space SSI. The clinical nurse specialist in
Orthopaedic surgery report any wound issue to the IP&CN. They meet on a monthly
basis to discuss patients. See Figure 4.
Surgical Site Infection (SSI) rate in Hip surgery from 2009 - 2011
SSI rate in Hip
2009 2010 2011
Surgical Site Infection (SSI) rate in Knee surgery from 2009 - 2011
SSI rate in
2009 2010 2011
Figure 4 Surgical Site Infection (SSI) rate in Orthopaedic Surgery from 2009- 2011
ALERT ORGANISM SURVEILLANCE
The IP&CN communicates daily with the Microbiology laboratory or by access to the
laboratory computer system. This allows prompt recognition of patients with
transmissible infections and recognition of outbreaks of infections. Organisms
included in this surveillance are
Resistant Staphylococcus aureus
(MRSA), Vancomycin resistant enterococcus (VRE), Clostridium difficile
and other multi drug resistant organisms.
All Notifiable diseases are reported by the
Microbiological laboratory and a record of these is kept on a shared drive.
METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) SURVEILLANCE
A targeted MRSA screening policy is in place for high-risk patients on admission to
Blackrock Clinic. In response to this an eradication protocol for these patients remains
in place. Hospital acquired MRSA (develops 48 hours post admission) and patients
diagnosed on admission are distinguished (Figure 5
). There was a reduction in
hospital acquired MRSA in 2011 by over 50%. In 2010 there were 7 hospital acquired
MRSA cases (including one infection). In 2011 there were 3 hospital acquired MRSA
Where possible MRSA colonised patients are decolonised prior to admission. All high
risk patients going for surgery without MRSA results are commenced on a
prophylactic decolonisation programme. An MRSA care pathway remains in place to
guide care for the MRSA patient. Yearly Staff screening for MRSA is in place in all
Colonised MRSA diagnosed on Admission VS Hospital Acquired 2011
Hospital acquired rate, 2011 is 0.006% per 10,000 bed days
Figure 5, MRSA diagnosed on admission swabs VS hospital acquired MRSA
(diagnosed 48 hours after admission)
There were no cases of MRSA bacteraemia in 2011. We are heading into our fifth
year without an MRSA bacteraemia. This was achieved by implementing an
intervention programme to prevent MRSA and other infections which consisted of:
• A mandatory education and training programme in intravenous care, for clinical
• A zero tolerance approach to poor hand hygiene.
• Weekly screening of patients in high risk areas for MRSA colonisation
• Staff screening for MRSA in all high risk areas.
• Strict isolation of patients with MRSA.
• Prophylactic topical treatment of high risk surgical patients on which no
information on MRSA carrier status is available before surgery.
• The introduction of Care bundles for Intravenous device care
METICILLIN SENSITIVE STAPHYLOCOCCUS AUREUS (MSSA) BLOOD STREAM
INFECTION (BSI) RATE
We monitored all positive bacteraemia in 2011 before the introduction of care
bundles. The bundles that were introduced were for peripheral and central venous
There were 14 positive blood cultures in total in the first six months of 2011.
introduction of Care Bundles in June 2011, the bacteraemia rate was reduced by 50%.
There were 4 MSSA bacteraemia and this was also reduced by 50% since the
introduction of care bundles. See figure 6
Meticillin Sensitive Staphlococcus aureus (MSSA) blood stream infections (BSI)
MSSA BSI rate is 0.009%
MSSA blood stream
Figure 6, Positive MSSA Blood stream infection in 2011 (pre and post introduction of
VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE)
Three patients acquired Vancomycin Resistant Enterococcus (VRE) in 2011. This
means the hospital acquired rate for VRE is 0.007%. It did not cause infection to any
of the three patients as it was colonised in their gut. All ICU patients are screened for
VRE on admission to the unit and weekly after that. This will ensure prompt
recognition of patients that carry VRE and therefore help avoid cross contamination.
VRE diagnosed on admission vs Hospital Acquired 2011
Hospital acquired rate is 0.007% per 10,000 bed days
Dx on adm Hospital acq
Figure 7 VRE diagnosed on Admission VS VRE hospital acquired infection rate
CLOSTRIDIUM DIFFICILE DISEASE
There was an increase in Clostridium difficile
in 2011. This was mostly due to
admissions from the emergency department. There were 18 cases of Clostridium
diagnosed in 2011. The hospital acquired rate was 0.02%, which is well
below the HPSC target. To improve both sensitivity and specificity of laboratory
testing the laboratory changed the testing algorithm in 2011 to a two step approach
consisting of Glutamate De-hydrogenase (GDH) and Toxin testing. Ambiguous results
are confirmed by PCR testing. See Figure 8
Overall Clostridium difficile patients for 2011
Hospital acquired rate is 0.02% per 10,000 bed days
Dx on/pre admission AAD
Figure 8 Clostridium difficile diagnosed on admission and Clostridium difficile
There were no cases of Norovirus in 2011. We continue to advise our patients to
contact us before routine admission, if they have symptoms of diarrhoea or vomiting.
Extended-Spectrum Beta-Lactamase (ESBL)
ESBL-producing E. coli
cause the same types of infections as other strains of E. coli.
(Extended-Spectrum Beta-Lactamase) are enzymes produced by some strains of E.
conferring resistance to most beta-lactam antibiotics. Infections caused by ESBL
producing bacteria are therefore harder to treat. See Figure 9
ESBL diagnosed on Admission vs Hospital Acquired 2011
Hospital acquired rate is 0.004% per 10,000 bed days
Figure 9 Extended-Spectrum Beta-Lactamase (ESBL) bacteria acquired in Blackrock Clinic
Carbapenem-resistant Enterobacteriaceae (CRE)
Carbapenem antibiotics have been invaluable for the treatment of infections caused by
multi resistant Gram-negative organisms over the last decades. The increasing rates of
Gram-negative isolates expressing carbapenem-hydrolyzing enzymes are posing a
significant threat for the usage of carbapenem antibiotics. Detection of unidentified
carriers is essential for successful control. Active surveillance was introduced in
2011. The committee’s recommendation is to screen patients who have been
inpatients for more than 48h in healthcare facilities in Ireland reporting outbreaks with
CRE as per HPSC website. There were no cases of CRE detected in 2011.
The Blackrock Clinic commenced a major development project in 2008. During 2011
the IPCT remained actively involved throughout the ongoing construction outside and
with in the hospital, both in advising on the provision and design of facilities within a
variety of projects. The IPCN closely monitored activity during each project.
Risk assessments of works were carried out and are available on Q Pulse. Dust checks
were carried out by the accommodation supervisors. Any increase in dust levels was
immediately reported to the construction manager and work was stopped until the
problem was investigated and resolved. In these cases air sampling was carried out
using fungal media. HEPA filtration was implemented in high risk patient areas
throughout the hospital as a preventative measure. There are a number of smaller
There were no cases of hospital acquired Aspergillosis in 2011.
OUTBREAKS OF INFECTION
There was one VRE outbreak in 2011. This occurred in ICU in October 2011. It
affected 2 patients. Both patients were colonised wit VRE and did not require
treatment. We continue to screen all patients being admitted to ICU for VRE and
weekly thereafter. In response to the outbreak hand hygiene education was provided
in the unit. The infection control CNS also spoke to nurses in small groups about the
incident. There were no further cross contamination cases in ICU.
The IP&CN continues to attend the hygiene committee that meets on a weekly basis
within clinical areas. Clinical managers or staff in charge is invited to attend to
discuss various topics within their area. A visual inspection of the area is also carried
out and reported to each manager. All heads of departments receive minutes of these
meetings. There is a patient information leaflet supplied to all bedrooms so patients
are aware of how their room is cleaned. The IP&CN introduced cleaning tags for
clinical equipment. All equipment that is put in a store room is tagged and signed.
This helps the staff take responsibility when it comes to cleaning equipment correctly.
This process was audited throughout the year and the average audit result for
Blackrock clinic encourages all staff to avail of the influenza vaccination yearly. This
can reduce transmission to vulnerable patients within the hospital.
There is a Hepatitis B vaccination programme for all clinical and accommodation
staff pre employment. Personal protective clothing is supplied to all clinical areas to
reduce the risk of exposure to body fluid. There is an Occupational health facility that
Blackrock staff have access to. They can help with advice and treatment, where
ANTIMICROBIAL THERAPY IN 2011
JOINT COMMISSIONER INTERNATIONAL (JCI) SURGICAL CARE IMPROVEMENT
PROJECT (SCIP) MEASURE
The audits were carried out by the Pharmacist that is represented on the IP&CC.
1. The first audit looked at antibiotic prescribing in Orthopaedic surgery:
• Timing of antibiotic prophylaxis administration in TKR and
• Antibiotic prophylaxis selection in TKR and THR
• Duration of prophylaxis in TKR and THR
The Audit tool was designed and a Pilot was conducted. Data collected for February
and May 2011. To validate the audit tool 200 cases were looked at by a second
person. Compliance was assessed using the antimicrobial prescribing guidelines
issued for the hospital. There were 6 discrepancies which resulted in 97% validity.
(d/c within 24
Three indicators measured in orthopaedic surgery (total hip and knee replacement)
A subcommittee was formed to review the Blackrock Clinic Antimicrobial
Guidelines. A number of changes were made to the document, which are to include
guidelines for Glycopeptides and Aminoglycoside prescribing and monitoring.
Guidelines were sent to the Consultants, the wards and the other medical staff in the
Many thanks to the Infection Prevention and Control Committee and all the staff in
Blackrock Clinic for all their help and support throughout 2011.
Document approved by The Infection prevention and control committee April 2012
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