Connolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March 2013

Transcription

1 Connolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March Summary The Infection Prevention and Control Quality Improvement Plan clearly defines the priorities for Connolly Hospital Blanchardstown in relation to infection prevention and control as agreed by the Infection Prevention and Control Committee (IPCC). This QIP incorporates three key plans into one overall QI plan for CHB for 2013, which needs to be reviewed at regular intervals and progress monitored by IPCC. The three key plans are: 1. The HIQA report recommendations from the announced visit of 29 th November The QIP submitted to the HSE in response to the PPS of The annual infection prevention and control programme The success of implementing this plan is dependent all CHB employees understanding their responsibilities and the actions they must take to reduce HCAI in CHB. It is also dependent on full staffing of the IPCT which is 2 WTE Clinical Nurse Specialists, 1 WTE Surveillance Scientist, 1 WTE Antimicrobial Specialist and 1.5 Microbiologists (0.7 hrs dedicated to infection prevention and control). In 2012 this level of staffing was not maintained in that the CNS complement was 1.0 from February to May and 1.5 WTE from May onwards, the Surveillance Scientist post was 0.5 WTE for all of 2012 and the Antimicrobial Pharmacist post was 0.6 WTE from October. Ongoing failure to maintain the IPCT staffing in 2013 will result in failure to successfully implement this plan in full. Infection Prevention and Control QIP 2013

2 2. Overall aims of Connolly Hospital Infection Prevention and Control Quality Improvement Plan To reduce preventable health-care-associated infections by a process of: Corporate and Clinical Governance of the prevention and Appropriate and safe device management control of healthcare associated infection (HCAI) Continue voluntary surveillance/reporting. Promotional Campaigns Develop, update and disseminate Infection Prevention and Response to local/regional/ national initiatives Control Guidelines Education/Training for staff Compliance with hand hygiene by all HCWs Audit and feedback to relevant staff of Infection Prevention Antimicrobial Stewardship and Control Practices Work to achieve compliance with HIQA National Standards Monitor and update KPIs with departmental feedback/interaction for Prevention and control Of HCAI Perform RCA on hospital acquired S. aureus bacteraemias and Promotion of Link practioner program Hospital acquired C. difficile work plan CHB Infection Prevention and Control work plan for 2013 will be a continuation of ongoing work identified in the 2012 work plan and new initiatives highlighted in section 4 below. Infection Prevention and Control QIP 2013 II

3 4. Quality Improvement Plan/New Initiatives for 2013 Initiative/Action to be Addressed Clinical Governance of Prevention of HCAI: Ensure the Hospital Executive takes an active part in ensuring that Healthcare- Associated Infections are reduced to a minimum Action Required Lead Responsible Timescales Update The Hospital Executive Committee (HEC) will receive and recommend required actions from the Annual report. The HEC will receive infection control updates and recommend required actions at each meeting HEC/ Infection Prevention and Control Team (IPCT)/Infection Prevention and Control Committee (IPCC) Present Annual Report for approval at HEC in April Review the clinical and corporate governance structure for the prevention of HCAI in CHB (HIQA report recommendation 2 and 3.) Infection control issues to be a standing item on departmental clinical and corporate governance meeting agendas with any relevant incident or root cause analysis or incidents being discussed. Analysis to continue to be sent to risk as at present also, and those categorised as serious to be discussed at Chair IPCC, Monthly Infection Prevention and Control QIP 2013 III

4 Continue to embed a culture of hand hygiene in CHB (HIQA recommendation 5) Clinical Governance &Quality Committee as at present, and also notified to medical board and nursing management team for wider dissemination of learning. Clinical Governance Quality and Safety Committee will receive an infection control update annually Ensure that all CHB employees (including locum staff and students) have mandatory programme of education and training on the prevention and control of infection, including Hand Hygiene, in order to understand responsibility for infection control and the actions they must personally take. Chair IPCC, HEC/ HR/IPCC/IPCT Annually Immediate and ongoing for 2013 Ensure protected time Hospital & Nursing Immediate Infection Prevention and Control QIP 2013 IV

5 required for staff to attend hand hygiene/ standard precautions education sessions Management Promote HSE e-learning programme. Embed e- learning as a modality for annual updates IPCT Launch March 2013 Root Cause Analyses (RCA) S. aureus bacteraemia and Clostridium difficile infection to ensure designated clinical responsibility for corrective action (Recommendation 1 HIQA report) Purchase Surewash Hand Hygiene System to aid hand hygiene education Root cause analysis focused on ensuring that action/learning is taken as a result and infection control issues to be a standing item on departmental governance meeting agendas with any relevant root cause analysis or incidents being discussed. Root cause analysis to continue to be sent to risk as at present also, and those categorised IPCT IPCT/IPCC/ Clinical Director/Director of Nursing Dependant on regional funding As cases arise Infection Prevention and Control QIP 2013 V

6 as serious to be discussed at Clinical Governance &Quality Committee as at present, and also notified to medical board for wider dissemination of learning. Perform RCA for all CHB acquired S. aureus bacteraemias and C. difficile infections. IPCT/ IPCC January 2013 Review recommendations with Clinical Director, appropriate Nursing and Clinical Personnel to ensure recommendations are implemented. Circulate reviews of RCA s and relevant learning points to all Clinical Staff IPCT/IPCC/ Clinical Director/Director of Nursing January Revision of the Clinical Governance and Quality IPCC Chair Six Monthly Infection Prevention and Control QIP 2013 VI

7 Committee agenda to specifically include Review of RCAs done by the Department of Clinical Microbiology wherein there is trend analysis and assurance of closing-out all recommendations made in RCAs. Device Management: Implement Care bundles hospital wide (HIQA recommendation 4) Peripheral Vascular Catheter (PVC) Care Bundle Central Venous Catheter/PICC line Care bundle. Ensure CVC Insertion Checklist Revise PVC care bundle and integrate PVC daily Care Sheet into bundle. Ensure PVC bundle used on daily basis and weekly care bundle compliance data completed and returned Develop and implement CVC/PICC care bundle on all wards Audit CVC Insertion Checklist PCT/IPCC/NPDD/ Director of Nursing and Nursing Personnel Director of Nursing/ Nursing Personnel/NPDD/IP CT IPCT/ Anaesthetic- Critical Care Department Team March 2013 June 2013 June 2013 Infection Prevention and Control QIP 2013 VII

8 in use for all CVC s Early identification of risk issues (HIQA recommendation 7) Ensure that the revised Integrated Admission and Discharge Planning Policy, which incorporate the prioritisation of single rooms, when required, for the accommodation of patients with suspected or known transmissible disease over the accommodation of private patients is complied with via audits, development of KPIs with review of targets, etc. Director of Nursing / Patient Flow Team-Bed Manager/ Nursing Management Immediate with 3 monthly update to IPCC Ensure Standard Operating Procedure manages patients with suspected or known transmissible disease in ED (effective December 2012) Director of Nursing/Patient Flow Team/ Bed Management/ Nursing Management Immediate with 3 monthly update to IPCC Develop and Implement Connolly Hospital Isolation Priority Score (CHIPS) Director of Nursing/ Nursing management/ ED/ June 2013 Infection Prevention and Control QIP 2013 VIII

9 Hygiene Services (HIQA recommendation 7) Ensure the revised SOP for the Cleaning of Isolation Rooms and SOP for cleaning of other rooms is implemented and adhered to. Patient Flow-Bed Management/Clinical Teams in association with IPCC Household Services Officer Immediate with update to IPCC Ensure Refresher training/education programme is provided to all Household Staff and all Contract Cleaning Staff on the above revised SOP. Household Services Officer Immediate with update to IPCC Ensure compliance with HSE Hygiene Standards through the development of a Hygiene QIP Director Nursing/ Committee of Hygiene June 2013 Extend Surgical Site surveillance (HIQA recommendation 6) Explore the feasibility of extending SSI surveillance to other surgical AG/EON/Clinical Director/Surgical Consultants Entirely dependent on restoring 0.5 Surveillance Scientist Infection Prevention and Control QIP 2013 IX

10 procedures Implement RCSI Quality Improvement Tool for prevention of SSI Consultant Surgeons Post AND facilitated by surgical teams Update to IPCC via Theatre users group Staffing Maintain IPCT staffing levels. Fill vacant 0.5 CNS and 0.5 Surveillance Scientist posts. Restore Senior Antimicrobial Pharmacist post to 1.0WTE Develop and Introduce 1. Recruit Link Infection Prevention Representatives. and Control Link Representative Programme 2. Establish the Link programme and role of the Representative within the organisation. HSE/Hospital Management IPCT/IPCC IPCT/IPCC Immediate Priority for 2013 Priority for 2013 Antimicrobial stewardship Distribute new pocket sized antibiotic guidelines IPCT January 2013 Audit and develop IPCT April 2013 Infection Prevention and Control QIP 2013 X

11 algorithm/care pathway for management of communityacquired respiratory tract infections Implement antibiotic care bundle and audit individual components -dependant on national kardex and staffing IPCT October 2013 Infection Prevention and Control QIP 2013 XI