Shetland NHS Board Control of Infection Committee Annual Report April March 2010 FINAL VERSION

Transcription

1 Shetland NHS Board Control of Infection Committee Annual Report April March 2010 FINAL VERSION

2 NHS Shetland Control of Infection Committee Annual Report Acronyms and Abbreviations ARI AOBD CDU CoIC CSBS HAI HAI SCRIBE HDL HEAT targets HPS ICM ICT NES MMR PFPI PPE MRSA MSSA QIS SAB SGS SIGN SHOR SPSP SSHAIP SSIS Aberdeen Royal Infirmary acute occupied bed days Central Decontamination Unit Control of Infection Committee Clinical Standards Board for Scotland Healthcare associated infection Healthcare Associated Infection System for Controlling Risk in the Built Environment Health Department Letter Health, Efficiency, Access, Treatment Targets Health Protection Scotland Infection Control Manager Infection Control Team NHS Education Scotland Combined measles, mumps and rubella vaccination Patient Focus Public Involvement Personal Protective Equipment Meticillin Resistant Staphylococcus Aureus Meticillin Sensitive Staphylococcus Aureus Quality Improvement Scotland Staphylococcus Aureus Bactereamia SGS UK Ltd Systems and Services Certification Scottish Intercollegiate Guideline Network Scottish HAI Outbreak Online Reporting System Scottish Patient Safety Programme Scottish Surveillance of Healthcare Associated Infection Programme Surgical Site Infection Surveillance 1

3 NHS Shetland Control of Infection Committee Annual Report Contents 1 Introduction Remit of Control of Infection Committee Accountability Committee Membership 5 2 Background to Work Programme Healthcare Associated Infection 9 3 Progress against Work Programme Surveillance Training Policy and Procedure Development Prevention of Healthcare Associated Infection Patient Safety Programme Audit Hospital Capital Plan Patient Focus Patient Involvement 20 4 Occupational Health 21 5 Communicable Disease Control Public Health etc (Scotland) Act Vaccination and Immunisation Group Emergency Planning 24 6 Significant Incidents 24 7 References 26 Appendices 27 Appendix A: Communicable Disease & Infection Control Surveillance Report Appendix B: Work Programme for Appendix C: Requirements and Recommendations of HEI Inspection Report: Gilbert Bain Hospital, NHS Shetland Appendix D: HEI Inspection Report Action Plan 2

4 NHS Shetland Control of Infection Committee Annual Report Introduction Infection control covers a wide range of activities. These range from preventing patients picking up infections when they come into hospital, to controlling outbreaks of infectious diseases, such as food poisoning, in the community. Although much activity is coordinated by the Infection Control Team (ICT) led by the Director of Public Health and the Infection Control Manager (Director of Nursing) as Executive Lead for Healthcare Associated infection, many others are involved in infection control activities. These include NHS clinical staff, cleaning staff and the Estates Department and the Shetland Islands Council s Environmental Health Department. The Control of Infection Committee (CoIC) acts as the central committee to oversee all infection control issues within Shetland NHS Board. In 2009 the constitution of the Committee was revised to bring it up to date with new roles and responsibilities within the Board, and the membership and remit of the Infection Control Team was similarly reviewed. 1.1 Remit of Control of Infection Committee To review and provide advice on Shetland wide infection control strategies and policies within the service To facilitate collaboration and co-ordination between different health service sectors, Shetland Islands Council and other agencies and to liaise with neighbouring NHS Board Control of Infection Committees To provide advice and support to the ICT and to assist the Director of Public Health in providing advice to hospital and community services To endorse the annual infection control programme prepared by the ICT To prepare an annual report for the Board, presented through risk management and clinical governance channels to the Clinical Governance Committee 1.2 Accountability The Control of Infection Committee regularly reports (and also in the event of a significant incident or outbreak) via the Clinical Governance Coordinating Group and Health and Safety Committee to the Clinical Governance Committee. The Clinical Governance Committee is the Board appointed Committee for health and safety and clinical governance matters in NHS Shetland. The Control of Infection Committee receives reports from the Control of Infection Team, and also a direct report in the event of a significant incident relating to infection control, or outbreak. 3

5 NHS Shetland Control of Infection Committee Annual Report Shetland NHS Board Clinical Governance Committee (Risk Infection Control Manager (Executive lead for HAI) Health and Safety Committee Annual Report Clinical Governance Coordinating Group Control of Infection Committee Vacc & Imm Group Cleanliness Champions Infection Control Team 4

6 NHS Shetland Control of Infection Committee Annual Report Committee membership April 2009 March 2010 (* Member of Infection Control Team ICT) Director of Public Health Consultant in Public Health (Deputy for DPH) CDU Manager / Infection Control Nurse (Hospital) Sarah Taylor* Susan Laidlaw* Carol Colligan (ICN (Hospital) Until August 2009 Infection Control Nurse (Hospital) Tina Bokor-Ingram (from August 2009) Infection Control Manager Public Health Nurse Lay Representative CHP representative / Asst. Director of Nursing (Community) Asst. Director of Nursing (Hospital) Consultant Microbiologist Estates Manager/Head of Estates Nina Fraser* Wendy Hatrick* Hazel Gray Edna Mary Watson* Janice McMahon* Tom Reid (Until October 2009 replaced by Annemarie Karcher) (based in Aberdeen) David Wagstaff/John McBeath Laboratory service rep Pam Ivens to January 2009 Les Phipps from January 2009 Occupational Health Nurse Pharmacy Manager Medical Director or rep Cleanliness Champion rep Sodexho Hotel Services Manager or rep NHS Grampian Infection Control Manager SIC Environmental Health Services Manager Facilities Manager Trudi Barnes to January 2010 replaced by Bernadette Dunne in May 2010* David Anderson Ken Graham Edna Peterson Ailsa Clews John McKinnon Maggie Dunne Magnus Flaws 5

7 NHS Shetland Control of Infection Committee Annual Report Background to Work Programme The work programme covers a number of areas concerned with infection control both in health care settings and the community. These include: surveillance training policy and procedure development prevention and management of healthcare associated infection audit As in previous years, most of the work programme for was based on developing and implementing local action plans concerned with the prevention and management of healthcare associated infection (HAI), a national priority for the Scottish Government. There are three main areas within this priority (infection control including hand hygiene, decontamination and hospital cleaning) and each is subject to national standards and recommendations. Infection Control NHS Quality Improvement Scotland (QIS) HAI Standards 1 Decontamination Hospital Cleaning Watt Group Report (2002 following Salmonella outbreak in a Glasgow hospital) 2 HDL (2005) 7 Infection Control and Cleaning: Nursing Issues 3 HDL (2005) 8 Infection Control: Organisational issues 4 NHS Scotland Code of Practice for the local management of hygiene and healthcare associated infection 5. NHS Quality Improvement Scotland (QIS) HAI Standards The Glennie Framework (2001) further standards for decontamination 6 Further guidance on primary care compliance with decontamination standards NHS Quality Improvement Scotland (QIS) HAI Standards The NHS Scotland National Cleaning Services Specification (published in 2004 by the Healthcare Associated Infection Task Force) 7 National Cleaning Services Specification Monitoring Framework 8 The HAI Taskforce Delivery Plan and the HAI Action Plan both have had an impact on all of the above. 6

8 NHS Shetland Control of Infection Committee Annual Report HAI Taskforce Delivery Plan In 2003, the Scottish Executive Healthcare Associated Infection Taskforce was set up in response to the Ministerial Action Plan Preventing infections acquired while receiving healthcare. 9 The Taskforce produced a programme of work which aimed to co-ordinate and build on existing HAI activities across healthcare settings in Scotland, based on the message: 'clean healthcare environments, clean hands, clean instruments'. In 2006 the Taskforce published a Delivery Plan for , which includes further work on the areas listed above, along with new initiatives such as the National Hand Hygiene Campaign. HAI Action Plan (in response to Vale of Leven C diff outbreak) In 2008 there was an outbreak of Clostridium difficile at the Vale of Leven Hospital in NHS Greater Glasgow and Clyde. 55 patients developed CDAD and 18 died. As a result of this there was an Independent Review and a number of issues were identified that had contributed to the problems at Vale of Leven. The Scottish Government subsequently produced a HAI Action Plan to address these issues and ensure good infection prevention and control procedures are in place across all NHS Boards. 2.1 Healthcare Associated Infection (HAI) QIS Standards and Healthcare Environment Inspectorate Scotland (HEIS) Inspection In March 2008 QIS published new HAI Standards for local assessment, and key actions in relation to these were included in the work programme for These standards focus on compliance, patient focus and public involvement, prevention and control of infection, environment and equipment, and education. Their aim is to build on the previous HAI standards, which focussed on structure and processes, and now to focus on outcome measures that will demonstrate improved Board performance. They recognise the importance of the NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Acquired Infection in the development of these standards, to build on work already implemented by the service. The detail of continuing to work towards compliance with the standards was included in the work programme for 2009/10. All NHS Boards were required to complete a selfassessment against the QIS Standards by June 2009 in preparation for the HEI inspection visit. More detail of the HEIS will follow. Background to Healthcare Environment Inspectorate Scotland (HEIS) Inspection The Healthcare Environment Inspectorate (HEI) made its first inspection visit to Gilbert Bain Hospital, NHS Shetland on 15 December Some background, purpose and the outcome of the HEI visit are detailed below. In November 2008, the Scottish Government produced a consultation paper entitled Healthcare Associated Infections Inspection, Assurance and Public Confidence. A new Inspectorate based in NHS Quality Improvement Scotland (NHS QIS) was thereafter established in April 2009 and named the Healthcare Environment Inspectorate (HEI) to undertake announced and unannounced inspections to each acute hospital in NHS 7

9 NHS Shetland Control of Infection Committee Annual Report Scotland at least once every 3 years. In addition, there will be an NHS board inspection annually. Reports following each inspection are published and a national overview will be published annually. In June 2009 the Chief Inspector, Susan Brimelow was appointed. The Inspectorate comprises a core team of Inspectors plus a number of co-opted experts. The functions of the Inspectorate are to: develop a proactive and assertive approach to NHS board self-assessment and supporting evidence requirements, establish a robust methodology for the analysis of that evidence for the purposes of validation, risk assessment and targeting for scheduled and random inspections, ensure rigorous inspections, drilling-down from NHS board level to hospital level down to ward/clinical level, provide continuous oversight of NHS board improvement plans, make its findings public, make recommendations to Scottish Ministers. The Inspectorate ensures that patients are at the heart of everything it does by being accessible to the public and measuring things that are important to patients. Purpose of HEIS The focus of HEIS is to reduce healthcare associated infection (HAI) risk to patients through a rigorous inspection framework. Specifically HEIS will focus on: providing assurance to the public, NHS boards, and the Scottish Government that patients are as safe as possible from HAIs and their consequences, that HAI standards in NHS acute hospitals are high, and that any HAI issues are being tackled. improving infection prevention measures across Scotland through an inspection framework, leading to a decrease in HAIs and their consequences over time. In addition, HEIS will draw on and contribute to the broader improvement agenda across NHS Scotland. HEI Inspection Report: Gilbert Bain Hospital, NHS Shetland The HEI inspection team examined NHS Shetland s self-assessment information and then inspected the hospital to validate this information, meet patients and staff, and visit wards and departments. During the visit, the inspection team also assessed the hospital s physical environment for issues related to healthcare associated infection. The findings from the visit set out five requirements (which are linked to compliance with NHS Quality Improvement Scotland healthcare associated infection standards) that NHS Shetland is fully expected to address, plus seven recommendations for improvement. The full HEI inspection report and an improvement action plan developed by NHS Shetland to address the identified issues are available (and included at Appendix D) to view at Speaking of the report, Susan Brimelow, HEI Chief Inspector, said: The inspection team observed that the majority of areas inspected were very clean and that there were some 8

10 NHS Shetland Control of Infection Committee Annual Report innovative ways to communicate and reinforce the importance of good hand hygiene. However inspectors also found areas for improvement and have identified five requirements and seven recommendations to help reduce the risk of healthcare associated infection. In particular NHS Shetland must look at the design and number of hand washing facilities provided in some clinical areas, to ensure they meet with current guidance. We fully expect the report s requirements and recommendations, which have been agreed by senior staff at NHS Shetland, will be addressed urgently, and the necessary improvements made as a matter of priority. Progress against the Action Plan is ongoing; all actions against the Recommendations bar one have now been completed. 3 Progress against Work Programme for Surveillance Surveillance is the collection and analysis of information about cases of illness, for example infectious diseases. It is used to understand patterns of illness, particularly to pick up where there is an unexpected increase in the number of cases of a disease. Surveillance is the responsibility of the Public Health Department in NHS Shetland. The Infection Control Team receives monthly surveillance reports to oversee action taken in response to cases or trends in infection. The Committee receives regular surveillance reports on MRSA; Staphylococcus aureus bacteraemias; Clostridium difficile; Surgical Site Infection Surveillance; sharps injuries amongst NHS staff, notifiable diseases and vaccination uptake rates. The Annual Surveillance Report (Appendix A) contains further details of the items summarised below. MRSA (Meticillin Resistant Staphylococcus Aureus) MRSA is a bacteria carried by many people that can sometimes cause serious infections, particularly in hospital patients. MRSA is identified in two ways: Screening of high risk patients (eg those transferred from a mainland hospital) Isolating MRSA as a cause of infection (for example a wound swab or urine test) Since January 2010, we have been implementing the national MRSA Screening Programme (more detail presented in Prevention of Hospital Acquired Infection (HAI) Section 3.4.6, page 17). Staphylococcus aureus bacteraemia (SAB) Nationally, both meticillin sensitive (MSSA) and meticillin resistant (MRSA) staphylococcus aureus bacteraemias are monitored and reported. The national system reports cases of bacteraemia with control limits designed to show where variations in rates might be significant. The most recent national report was published in April 2010 as part of the first combined HAI Report from HPS. 10 This published data for the calendar year Staphylococcus aureus bacteraemia data have been monitored in Scotland since 2001 and there have been substantial reductions in these infections since this time. 9

11 NHS Shetland Control of Infection Committee Annual Report Meticillin resistant Staphylococcus aureus (MRSA) bacteraemias have reduced significantly over the last 3 years in NHS Scotland. The incidence of meticillin sensitive Staphylococcus aureus (MSSA) bacteraemias has also reduced. During , there was one case of MRSA bacteraemia in Shetland (in April 2009) and two cases of MSSA bacteraemia (in April and June 2009). However, because one patient had repeated positive results, a total of four cases of MSSA SAB were reported nationally. The other patient did not have a clinical bacteraemia, the result was thought to be due to skin contamination when the blood test was taken and subsequent tests were negative. The small number of episodes reported from Shetland mean that these numbers should be interpreted with due caution, and no conclusions about trends can be drawn. The biggest risk to maintaining the local rate is seen to be the importing of infections with patients travelling back to Shetland from mainland hospitals. At present there are strict controls in place for screening and isolation of incoming patients. These will continue, although pressure on beds with tougher waiting times targets and local redesign of services does make this increasingly challenging. A HEAT target was introduced for all Boards to reduce all Staphylococcus aureus bacteraemias by 30% by March The baseline for Shetland was one per quarter (or four per year) so the target was one case per year. As reported above, the number of cases reported in Shetland is low, and very small variations in numbers one or two cases, can change the rate disproportionately. Progress towards the target is monitored quarterly but using a rolling annual total. This meant that although there were no bacteraemias in Shetland between June 2009 and April 2010, the rolling average at the end of 2009/10 was five. Clostridium difficile Clostridium difficile is a bacterium, widely distributed in the environment and in the gastrointestinal tract of animals and also humans. Clostridium difficile infection (CDI) is a major cause of illness and death, especially as a healthcare associated infection. It usually follows use of antibiotics, with some antibiotics being more likely to trigger infection than others. Disease ranges from mild self-limiting diarrhoea to severe diarrhoea, pseudomembranous colitis, toxic megacolon and potentially death. In recent years, the numbers of infections caused by Clostridium difficile have increased and become more severe. In Scotland, mandatory surveillance of CDI was introduced in 2006 as a result of this changing picture. The surveillance programme was initially set up to record the incidence of CDI in patients aged 65 and over. In April 2009, the programme was expanded to include the age group Cases are identified through laboratory reports (Shetland samples were previously tested in Aberdeen, but are now done locally). The first national Annual Report of the system was published in December 2007 and it provided reference baseline data for NHS Boards in Scotland. In Shetland it showed an annual rate per 100,000 inhabitants over 65 of 421, against a national average of 656. The local figure as a rate per total occupied bed days for care of the elderly beds was 0.77 (national average 1.27) and for acute hospital beds was 2.10 (national average 2.03) a difference that is not significant given the small numbers locally. 10

12 NHS Shetland Control of Infection Committee Annual Report National figures for 2009 were published in April 2010 in the combined Scottish HAI report. 10 These showed that there was one case of CDI in Shetland, in a person aged over 65 during the first quarter of the year. This gave a rate per 1000 acute hospital bed days (AOBD) of 0.05 (the overall figure for Scotland was 0.71) Local figures show that between April 2009 and March 2010 there were 3 cases of CDI in total, all in the first quarter of the year. One of these results was not clinically significant (it was an incidental finding). There have been no cases of CDI since May The quarterly figures are shown in Appendix A. Surgical Site Infection Surveillance (SSIS) Surgical site infections (SSI) are an important cause of healthcare associated infections (HAI). They account for 15.9% of all HAI, and cost the NHS in Scotland 30 million per year. 11 SSI have serious consequences for patients affected as they have been estimated to at least double the length of hospital stay and also result in pain, suffering and possible further surgery. SSI is an important outcome measure for surgical procedures and the key aim of SSI surveillance is to improve the quality of patient care and to provide participating hospitals with robust SSI rates in order for them to compare with similar hospitals against benchmark rates. Evidence suggests that actively feeding back data to clinicians contributes to reductions in rates of infection. The Scottish Surveillance of HAI Programme (SSHAIP) within HPS coordinates the SSI surveillance programme that is mandatory in all NHS Boards in Scotland. All NHS Boards are required to undertake surveillance for hip arthroplasty (for fractured hip) and caesarean section procedures as per the mandatory requirements of HDL (2006) 384 and CEL (11) Patients who have had hip arthroplasty are followed up to 30 days postoperatively if the patient remains in hospital, or is re-admitted within this period. Patients discharged home before the 30 days are followed up until the point of discharge. Patients who have had a Caesarian section are followed up until 10 days postoperatively, whether or not they have been discharged. The local data shows that we have a small number of procedures and a small number of infections, with no significant trends to date (see Appendix A). Communicable disease surveillance The Public Health Department is informed of cases of notifiable disease, both those suspected on clinical grounds, which are notified by the GP or a hospital doctor and those confirmed by the laboratory. This information is forwarded to Health Protection Scotland, which produces weekly updates on a national basis. In January 2010 the list of notifiable diseases and the methods for reporting them to Public Health changed as a result of the new Public Health Act for Scotland. 12 Some common infections have been removed from the list, including chickenpox and clinical suspicion of food poisoning (gastro-intestinal infection). Confirmed cases of salmonella, campylobacter and other gastro-intestinal infections are reported by the laboratory. Appendix A shows these figures in detail for , along with commentary on some of the specific infections reported. 11

13 NHS Shetland Control of Infection Committee Annual Report Vaccination uptake rates Childhood immunisations are managed and monitored through a local Vaccination & Immunisation Group, which reports regularly to the Control of Infection Committee. National uptake figures, broken down by NHS Board and CHP, are reported on a quarterly basis by National Services Scotland Information and Statistics Division (ISD). The Vaccination & Immunisation Group uses these reports to monitor trends and take action if necessary. The Immunisation Co-ordinator also receives uptake figures broken down by GP practice and feeds these back to individual practices. The uptake reports for the last three quarters, July 2009 to March 2010, have shown a decrease in the uptake of the primary immunisations by age 12 months, and also of the Hib Men C booster by age 24 months. This has been investigated and found to be due to a problem with the national database used for collecting information and sending out invites (SIRS). A small number of children did not receive an invite when they should have done and for other children although they had been given their vaccines and this had been recorded correctly, this information was not picked up by SIRS. The primary care teams are working hard to check the immunisations status of the children potentially affected, ensure the correct information is on SIRS and call in children for any vaccinations that they may have missed. Details of uptake are included in Appendix A. Sharps injury A sharps or contamination injury is when someone receives a puncture wound from a needle or other sharp instrument or object which could be contaminated and which may lead to infection. Also a person could come into contact with blood or body fluid that is blood stained through splashes in the eyes, mouth or broken skin or through a bite from a person. Although rare, there is the risk of contracting a blood borne infection such as HIV, Hepatitis B or Hepatitis C through a sharps or contamination injury. Across Scotland the annual incidence of sharps injury is approximately 15 per 1,000 staff. 13 Shetland NHS Board employs approximately 700 staff which gives us a rate for of 24.3 (17 injuries recorded). The local rate has remained fairly constant in recent years. Efforts have continued over the last year to increase awareness and training on sharps and blood borne viruses. There has been formal training in 2009 through the Staff Development Service. On pre employment Staff are given individual advice on sharps injury management. The new intake of Doctors will also be targeted on an individual basis on pre employment. The Occupational Health department continues to play a significant role in both raising awareness and training, and in responding to incidents. Incidents are logged and clinical areas that have had more than one incident have seen reductions by targeting them with additional support. 3.2 Training Induction & refresher days for all NHS staff The corporate induction day now in its seventh year has continually developed and continues to be delivered to all staff, except the junior doctors and Student nurses, as both of these groups have their own specific induction. The induction day has a number 12

14 NHS Shetland Control of Infection Committee Annual Report of specific sessions, delivered by experts, that the Board has decided are essential for all new staff to be made aware of and control of infection is such a topic. The first Monday of every month, when induction is delivered, requires a member of the infection control team to give a 15-minute presentation on infection control. This session is usually delivered by either the Director of Public Health or the Public Health Consultant. This indicates the importance to the new members of staff of infection control. Between April 2009 and March 2010, 78 new members of staff attended the induction session. Mandatory Refresher Training also runs every month and it is expected that every staff member, including bank staff, attend this course in an 18 month cycle. The course is reviewed and revised every 18 months and in this cycle there are a number of areas where infection control training is delivered. Firstly this day is split into two distinct parts; a morning where sessions are delivered in either presentation or practical session. The second part is for delegates to complete some Learn Pro e-learning modules. There is a practical session on infection control, which can be varied according to the needs of the staff attending, but generally involves an update on current issues and new procedures and also the opportunity to use the UV light box to check hand-washing technique. Again this session is usually delivered by a senior member of the Public Health Team. Evaluation of this session is consistently good. Between April 2009 and March 2010, 184 delegates completed this training. One of the Learn Pro modules that delegates are required to complete is on Health Care Associated Infection. So far 135 staff have completed this training including both clinical and non-clinical staff. There is an additional module for clinical staff on food hygiene: 135 have completed this module. Finally the optional module on safe transfusion has been completed by 87 staff. The student nurse induction has been updated and now includes a more comprehensive session on control of infection. This involves hand washing techniques and the proper use of gel dispensers. Training has taken place with Health Care Support workers and a series of courses has been developed to develop the skills of this group of staff. A session on HAI has been included and delivered to 13 delegates Decontamination: Central Decontamination Unit (CDU) staff: The fourth member of CDU staff has re-commenced the NVQ at Level 3 in Decontamination following her return from maternity leave. The CDU Manager has commenced the dissertation on the MSc in Medical Device Decontamination. There has been a nine month delay with this because the University had difficulty in finding and appointing a suitable specialist supervisor. All mandatory organisational training has been completed by all staff in the department. All CDU staff have an eksf PDP in place and are on target to reach the heat target of 100% KSF Development reviews by the end of March IV drug infusion training The IV drug administration programme is under review and no staff have undertaken training during the period of this report. It is envisaged that the revised programme will recommence in the Autumn underpinned by a new drug administration policy. 13

15 NHS Shetland Control of Infection Committee Annual Report Cleanliness Champions (NHS Education Scotland package) 233 staff have registered on the programme, 115 are progressing through the programme with no outcome yet. 23 have withdrawn from the programme mainly due to staff leaving the organisation. 95 staff have completed the programme. Staff have been supported to complete the programme by a number of means, for instance, protected time to complete the online programme with sessions held in the Staff Development Section Food handling training for ward staff There is a module on the Learn Pro package that all clinical staff must complete on food hygiene, as stated previously 135 staff members have completed this module Other training: Accident and Emergency staff Decontamination training run by the SORT team of Scottish Ambulance Service was run in Further training will be required if and when a new decontamination unit is installed. NHS Shetland is currently awaiting the delivery of a new decontamination tent however, due to the heaviness of the new tent it will require Estates staff to carry out the assembly at any training events or real incidents allowing A&E nursing staff to continue the decontamination process of the casualties. Embedding Infection control issues into all training We have continued over the past 12 months in the Board to mainstream and embed infection control issues into all clinical training courses. Gel pumps are in all training rooms and courses such as moving and handling (184 delegates attended), basic life support (191 delegates attended), immediate life support (32 delegates attended), catheterisation (8 delegates attended), venepuncture (8 delegates attended), Resuscitation Skills (2 delegates attended), Paediatric life support (42 delegates attended), involve scenarios where staff must use the dispensers appropriately to be successful. HAI issues are a major focus at both the corporate Induction day and also the local inductions staff have. These are audited for completion and we can be sure that 100% of our staff have a good induction around HAI. As in the previous year the Board, through the Staff Development Unit will continue to adopt this approach to ensure that infection control is a key element of all the training offered to Shetland NHS Board staff and becomes embedded in day to day practice. Staff Development Bulletin There is a new Infection Control section in the Staff Development Bulletin, which highlights key issues and training opportunities for all staff. It also contains a list of useful websites so that staff can access infection control information and training electronically and at a time that suits. 14

16 NHS Shetland Control of Infection Committee Annual Report Infection Control Team: individual training programmes Members of the Infection Control Team have also undertaken specific training within their Personal Development Plans. 3.3 Policy and Procedure Development Communicable disease / public health incident plans and procedures The following policies, procedures and plans were approved by the Control of Infection Committee during Communicable Disease Policy (the overarching policy for communicable disease control and infection prevention) Joint Health Protection Plan Pandemic Flu Contingency Plan ver 4.1 (updated) Generic Hospital Outbreak Plan Policy for Staff screening during an Outbreak (reviewed) The following procedures were also approved by CoIC: Procedures for the Prevention and Management of Tuberculosis Procedures for Death Certification How to fill in the medical certificate of cause of death Procedures for the Safe Management of Linen (reviewed) Hand Hygiene Procedures (reviewed) Personal Protective Equipment Procedures (reviewed) Procedures for Cleaning of Care Equipment (reviewed) Procedures for cleaning Unotron washable keyboards A number of other procedures and plans are due to be completed or reviewed during the first half of 2010/11: Procedures for the management of MRSA (To be updated to incorporate MRSA screening procedures) Generic Public Health Incident / Outbreak Plan (to be completed) Procedures for protection against occupational infection with blood borne viruses (to be reviewed) 3.4 Prevention of Healthcare Associated Infection (HAI) Infection control standards Cleanliness Champions The local Cleanliness Champions continue to take forward the programme of local work on the prevention of Healthcare Associated Infection, with a particular focus on hand 15

17 NHS Shetland Control of Infection Committee Annual Report hygiene during the past year. There is now a Board requirement that all qualified nurses and allied health professionals undertake the Cleanliness Champion training, but all staff are encouraged to consider doing the course. The Cleanliness Champions meet regularly with attendance at meetings increasing in the last year. A Cleanliness Champion representative sits on the Control of Infection Committee Hospital cleaning In our hospitals cleaning is carried out by our facilities management contractor Sodexho Heathcare. The cleaning methods and quality standards are set out in the NHS Scotland National Cleaning Services Specification. Cleaning standards are monitored on a regular basis both by Sodexho through their quality control system, and by NHS Shetland using the NHS Scotland cleaning monitoring tool. This latter system gives a numerical score with an overall target level of 90%. We have consistently exceeded the 90% target throughout with figures for compliance ranging between 94 and 98%. A representative from Sodexho is included as a member of the Control of Infection Committee and the Board s Facilities Manager reports regularly on cleaning monitoring information Decontamination The Central Decontamination Unit (CDU) at the Gilbert Bain Hospital provides a decontamination service to ward areas and departments for NHS Shetland. The Glennie Report 6 recommended that all decontamination (of surgical instruments and medical devices) should be carried out within a central processing unit. Complete centralisation of decontamination for Podiatry has been achieved. The centralisation of the dental workload continues with services from Whalsay being the most recent unit to be absorbed by CDU. A dental business case has been prepared for presentation to the board for compliant LDU dental decontamination facilities at the Brae and Yell Health Centres. The national LDU working group are informed of progress by NHS Shetland towards meeting the deadlines for Primary Care Compliance in Decontamination at national quarterly meetings. The business case has been approved for the replacement of both sterilizers and the replacement of the single cabinet washer disinfector to a multi chamber machine to increase capacity for the dental workload. The tender for the machines has just closed and contracts will be awarded shortly to the successful manufacturers. CDU have just successfully achieved re-certification to ISO 13485:2003 and the Medical Device Directive following the 2 day audit by SGS (Inspection Verification Testing and Certification Company) with only one minor non-conformance identified which has been the best result to date Surgical Site Infection Surveillance The Scottish Surveillance of HAI Programme (SSHAIP) within HPS coordinates the Surgical Site Infection Surveillance (SSI) Programme that is mandatory in all NHS Boards in Scotland. The local surgical team collects surgical wound infections data on a 16

18 NHS Shetland Control of Infection Committee Annual Report continuous basis. Data are presented at the monthly surgical audit meeting to discuss individual cases and any emerging patterns or trends to surgical site infections. More detail is presented in the Surveillance Section 3.1 (page 11) Hand Hygiene Campaign From April 2007 onwards, NHS Shetland has participated in the national hand hygiene campaign, with the appointment of a Local Health Board Co-ordinator (LHBC) who has led awareness and training, and conducted the local audits on hand hygiene within the national programme. These have been reported regularly into the Control of Infection Committee. Figures for 2009 and 2010 are shown in Appendix A and remain consistently high. The audit focussed on compliance with hand washing through observations of hand hygiene opportunities and testing the knowledge of staff through a survey asking key questions about local hand hygiene procedures. During hand hygiene audits anyone demonstrating non-compliance is given verbal feedback immediately and given written materials such as leaflet or pocket credit card sized reminders. Hand Hygiene is a major focus of Induction and Mandatory Training for all staff. Additional Hand Hygiene Training has been provided in clinical areas as required. In October over 200 Medical and Nursing staff attended this additional training. Basic Hand Hygiene Training was also given to outside contractors carrying out building works within local hospitals MRSA Screening Programme Background The programme commenced in January In addition to patients who are already screened for MRSA (ie. transfers from mainland hospitals and patients with a previous history of MRSA) all patients being admitted electively (for at least one night) and all those being admitted to care of the elderly wards ( ie Ronas and Vaila) should be now be screened for MRSA. Screening as part of the national programme consists of a nasal swab. If this is positive then a full screen is undertaken. The majority of the patients included in the programme are surgical patients who are seen in the pre-operative assessment clinic prior to admission for surgery. If they are not screened before admission, then they should be screened on admission to the ward. All other patients are risk assessed, and screened if deemed to be at higher risk of MRSA (for example those with previous MRSA or recently discharged from mainland hospital). Local progress Between 1 st January and 30 th April, there were 73 patients screened (by nasal swab) prior to elective admission and nine patients on admission or transfer to Ronas ward. Of these, one had a positive result. This was a patient admitted to Ronas ward who was successfully decolonised (ie three negative screens post-decolonisation). These figures are lower than the projected number of screens and it is not clear if this is because patients who should be screened are being missed, or because there are fewer than expected admissions. The project manager is auditing how many of the patients who should have been included in the programme have been screened. This information will be used to target awareness raising and training at any areas where the programme is not being fully implemented. 17

19 NHS Shetland Control of Infection Committee Annual Report In Shetland, the Public Health Department collects information on colonisation and all infections caused by MRSA and report these to the Control of Infection Committee. We also take part in the national surveillance system for MRSA bacteraemia (a serious blood infection caused by MRSA). When the Public Health Department receives a positive laboratory report, the referring ward or GP is asked to complete a local MRSA surveillance form. This allows for an investigation of the circumstances surrounding each case of infection, and identification of anything that could have been done differently to prevent the infection Prevention of Healthcare Acquired (HAI) Infection: QIS Standards Self-Assessment Key actions relating to the HAI QIS Standards were included in the 2008/9 Work Programme and Self-assessment was completed by June 2009, ahead of the first Healthcare Environment Inspectorate (HEI) inspection visit to Gilbert Bain Hospital. Development of Equipment Cleaning Service NHS Shetland has developed an Equipment Cleaning service to complement the cleaning already carried out by Sodexho and Ward staff. A dedicated equipment cleaner is employed to provide a service to the wards on a day-to-day basis. Implementation of Prioritised Action Plan for Estates A number of estates actions have been identified through the HAI SCRIBE audits completed in ; the preparatory work for the HEI inspection, and the environmental audits conducted in These are being prioritised based on the level of infection risk, along with other factors, to be included in the Board s maintenance plan or Capital Plan (depending on the level of work required). 3.5 Scottish Patient Safety Programme (SPSP) NHS Scotland is the first health service in the world to adopt a national approach to improving patient safety. The Scottish Patient Safety Programme is being co-ordinated by Quality Improvement Scotland (QIS) and aims to steadily improve the safety of hospital care right across the country. This will be achieved using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and practice. As part of the Critical Care Workstream we continue to monitor the Central Line Insertion Bundle, Central Venous Catheter (CVC) Maintenance Bundle and the Peripheral Vascular Catheter (PVC) Bundle in the HDU. The Consultant Anaesthetists ensure that details are updated on Wardwatcher (a national database system) and ward staff ensure that both CVC and PVC bundle compliance stickers are attached to patients notes. The current outcomes identify days between infections; Days between a Central Line Bloodstream Infection = +675 Days, Days between Staph. Aureus Bacteraemias (SAB) = +550 Days and days between a C. Difficile associated disease occurrence (ITU and HDU only) = +550 Days. Hand Hygiene compliance is also audited in the unit. The General Ward Workstream also includes outcome measures for SABs and C. Difficile disease occurrence; Days between SABs (General Ward & other non-critical areas) = +375 Days and Days between C. Difficile associated disease occurrence = +350 Days. Hand Hygiene and the PVC Bundle process measures monitor compliance levels monthly as part of the programme. 18

20 NHS Shetland Control of Infection Committee Annual Report SPSP improvement methodologies are now being integrated in Infection Control through the Infection Improvement and Implementation Programme (iiip). The alignment of these two programmes aims to ensure that everything done has a measurable, lasting effect on safety and quality in healthcare in terms of infection prevention and control. 3.6 Audit Audit activity has been focussed on the implementation of new and revised infection control procedures. The following audits were conducted during 2009/10: Outbreak Policy (looking at staff knowledge) (Alcohol) Hand Gel Audit Fridge audit (compliance with monitoring temperatures) Green tape audit (compliance with using green tape to mark cleaned equipment) Monthly Hand Hygiene audits in every clinical area Monthly Cleaning Specification audits in every clinical area An Environmental Audit has been developed to assess all aspects of infection control in clinical areas. This has been developed from the Healthcare Inspectorate inspection tool process. A baseline audit has been conducted with every clinical area to identify any areas of non-compliance and to prioritise the frequency of future audits. By the end of March 2010, the following areas had been audited: Ward 1 Ward 3 Maternity Ronas Ward Outpatients Renal Unit Accident and Emergency Department Laundry Basement Corridor Maternity Link Corridor Corridor Therapy Suite Children s Outpatients Porters Occupational Therapy Dental Gilbert Bain Labs 19

21 NHS Shetland Control of Infection Committee Annual Report Medical Imaging Unit Physiological Measurements Renal Front Reception Audiology Physiotherapy Day Surgery Unit Pharmacy Outpatients Pre-assessment CDU For each area, a list of practice issues has been generated, which are the service manager s responsibility for ensuring they are dealt with. There is also a list of Estates issues for each area, and although Estates has the responsibility to solve the problem, it is the service manager s responsibility to check that this is done. Once all areas have been audited, a prioritised timetable for future audits will be produced to ensure there is an ongoing audit cycle. 3.7 Hospital Capital Plan As part of the HAI SCRIBE process Infection Control issues are addressed within plans for all building works including the design of clinical areas; new fixtures, fittings and equipment and ensuring appropriate infection control measures are taken during building works. A report to CoIC meetings is as a standard agenda item. Repeat HAI SCRIBEs are carried out after all building works are completed. 3.8 Patient Focus Public Involvement Public membership of the Infection Control Committee was achieved in 2007 through a nomination made to Shetland NHS100. As of August 2010 NHS100 has now been superseded by the Public Partnership Forum and NHS100 members will automatically be transferred to the new group membership where work will continue to focus on HAI and specifically Hand Hygiene activity. Four meetings have been held this year with NHS100 relating to HAIs, this has included briefings about infection rates and types as well as a hand hygiene demonstration that each lay member took part in. NHS100 have also helped the Board with developing publicity about hand hygiene around the hospital as well as advising on an information poster for visitors to the hospital. Suggestions have also been made by NHS100 about the publicity of hand hygiene information around the reception area and these have been 20

22 NHS Shetland Control of Infection Committee Annual Report fed back to the appropriate managers. Actions planned from those suggestions were fed back to NHS100. Lay involvement within various hospital walk rounds has continued, including Environmental Cleaning and Hospital Cleanliness, with feedback being received at each PFPI Steering Group. This ensures that cleaning audits include a valued lay perspective which is quickly acted on. One information session has been held for lay members who have volunteered to take part in the patient safety leadership walk rounds. This is in preparation for the next cycle of walk rounds where the Board would like to formally introduce a lay perspective to patient safety. 4 Occupational Health The Occupational Health Department now has a full complement of staff and has been actively contributing to the work of the Control of Infection Committee and Infection Control Team. The OH staff are particularly involved in management, monitoring and training regarding sharps injuries. They have also been involved in the development of local policies and procedures. 5 Communicable Disease Control The Public Health Department has an ongoing responsibility for communicable (infectious) disease control in the hospital and the community. The main challenge for the Department during was the Influenza A H1N1 Pandemic. Whilst there were very few confirmed cases in Shetland, the response to the pandemic still created a significant workload for the Department until early In April 2009 a new strain of Influenza A (known as Swine Flu) subsequently identified as H1N1 started circulating internationally, and was formally identified as a pandemic in June 2009, circulating world-wide with cases across the UK including Shetland. A local multi-agency response was initiated with the formation of a Pandemic Influenza Control Team (PICT) under the Chairmanship of the DPH. This team co-ordinated responses across the NHS and other services throughout the summer and autumn of 2009, through the phases of containment and treatment, with considerable and detailed contingency planning. An increasing trend of Influenza illness peaked in July 2009 with a smaller second wave through September after which the incidence reduced. There were 68 deaths in Scotland attributed to H1N1, none occurring in Shetland. A major area of work which involved not just Public Health but primary care teams, the Occupational Health Department, Pharmacy and Community Nursing was the implementation of the H1N1 vaccination programme as part of the response to the pandemic. Public health staff also worked with clinical colleagues and emergency planning partners to plan and prepare potential massive increase in demand on services and reduction in staffing had a local outbreak occurred. Though the response involved significant effort from all parts of the service, and required the activation of business continuity plans particularly for the public health team, at no time were normal clinical services to patients disrupted in Shetland. The PICT was stood down in January 2010, though national surveillance continues, and H1N1 vaccination is now included in the national seasonal flu vaccination programme. 21

23 NHS Shetland Control of Infection Committee Annual Report In addition to managing the local response to the Flu Pandemic, the local Public Health Department has continued to deal with communicable diseases notified to the department; offering advice and instituting control measures where necessary, often in conjunction with Environmental Health. Staff have been involved in a range of activities including: Direct contact with and liaison between patients, the public, NHS staff, environmental health and others Dissemination of information including to patients, the public, NHS staff and the media Further development of departmental systems for surveillance and management of communicable diseases and related issues using computerised recording of cases and incidents. Delivery of training, both to NHS staff through the induction and refresher days and to other partner organisations, eg care homes, on request. Local implementation of the Public Health etc Act Scotland as detailed below. 5.1 Public health etc (Scotland) Act 2008 The Scottish Government have undertaken a comprehensive review of Public Health Legislation in order to ensure that it is prepared and able to protect Scotland from the global spread of disease and contamination. The Public Health etc (Scotland) Act 2008 has set out new powers and responsibilities to ensure public health threats can be addressed quickly. The Act focuses on protecting the community, or any part of the community, from infectious diseases, contamination or other hazards that constitute a danger to human health. A phased approach is being taken to implement the Act. Elements of the Act relevant to Communicable Disease Control include: Designation of competent persons to undertake functions assigned to them under the Act and which require professional input at a particular level A duty of co-operation placed on health boards and local authorities in exercising the functions under the Act, and for them to plan, together, for public health protection. (ie production of a Joint Health Protection Plan) A statutory notification scheme for disease, organisms and health risk states. Definition of a public health investigation and the powers available to investigators who may be appointed by the Scottish Ministers, a health board, Health Protection Scotland, a local authority or two or more of these persons acting together. The Act removes powers previously held by local authorities relating to infected people and assigns them to Health Boards. It gives new powers to Health Boards to restrict a persons activities to reduce the spread of contamination and infection, power to quarantine people and power to require a person to be disinfected or decontaminated where there is a significant risk to public health. The Act replaces the existing powers of Local Authorities with new provisions to order a range of Public Health Measures in relation to premises, and things, 22

24 NHS Shetland Control of Infection Committee Annual Report including disinfection, disinfestation and decontamination in order to prevent the spread of contamination or infectious diseases. The Act places a duty on health boards to ensure mortuary provision, including postmortem facilities, for hospital-related deaths. It also replaces provisions in the Public Health (Scotland) Act 1897 with regard to the handling of dead bodies in order to reduce the risk to public health with a new provision. The Act enabled ministers to implement the International Health Regulations. The new regulations are designed to control the international spread of disease without unnecessary interference with international traffic and trade. The Public Health team is working closely with Environmental Health colleagues in the implementation of the Act locally. During 2009/10 the revised statutory notification scheme was implemented and we produced a Joint Health Protection Plan which was approved by the Board in March Vaccination & Immunisation Group The Board s Vaccination and Immunisation Group meets regularly and reports to the Control of Infection Committee on uptake rates, and on local actions to improve uptake and comply with national policy. In 2009/10 the main area of work was implementation of the Influenza A H1N1 vaccination programme as part of the national response to the Flu Pandemic. This involved Public Health, primary care teams, Occupational Health, Pharmacy and Community Nursing, and was led by the Immunisation Co-ordinator through a local implementation team. The programme involved offered the H1N1 vaccine to all front line health and social care workers, all patients in clinical risk groups (similar to the seasonal flu risk groups); all pregnant women and all children under the age of five years. Over 50 staff received training in delivering the programme, and over 5,500 people in Shetland received the vaccine in the five month period from end October 2009 to March The programme is ongoing until the 2010/11 seasonal flu vaccination programme starts, when the new seasonal flu vaccine will contain the H1N1 strain. In addition to the H1N1 vaccination programme, we continued to deliver the following programmes: Childhood immunisation programme, through Primary Care Seasonal flu and pneumococcal programme, through Primary Care HPV immunisation programme for teenage girls, through School Health BCG programme for high risk individuals, through Child Health Hepatitis B vaccination for high risk individuals, through a range of services locally including the addictions services, the sexual health clinic, primary care and services in Grampian. Primary care teams also provide travel health advice and vaccinations to their patients and the Occupational health services provided the relevant vaccinations for health and other staff. The Immunisation Co-ordinator has been actively involved in promoting the on-line Immunisation Training Package. A total of seven staff have now completed the course and a further six are registered. Two local Immunisation Update Training sessions were 23

25 NHS Shetland Control of Infection Committee Annual Report run in , with a further session planned for April. These were evaluated as being very successful and they will continue to run on an annual basis. Details of local surveillance and uptake figures are included in Appendix A. 5.3 Emergency Planning The DPH is a member of the Shetland Emergency Planning Forum. The Forum meets at least annually and considers all types of local emergency including incidents that may affect the health of the public such as infectious disease outbreaks and biochemical hazards. The DPH, along with the Assistant Director of Nursing (Hospital), is also a member of the Forum Executive, which meets quarterly. An Emergency Planning Annual Report is produced annually and presented to Shetland NHS Board. During 2009 / 10 further progress was made in developing and updating the Board s Business Continuity Plans (BCPs), with all service areas (priority and non-priority, clinical and non-clinical) now having a BCP in place and updating plans to a standard template that prompts responses to the major potential impacts against timescales for recovery. Training in 2009 / 10 has included: The annual Emergency Planning Seminar in April 2009 Back to the Future. Extensive update training both for the public health team and for NHS staff (and partner agency staff) on the wide range of issues relating to the H1N1 Pandemic, from policy and strategic planning to business continuity testing, to infection control measures, the use of protective personal equipment (including the introduction of face mask testing and fitting), and the delivery of the associated vaccination programme. Training with individual departments within the NHS as part of the support for the development of Business Continuity Plans. Individual Continuing Professional Development (CPD) by members of the Public Health team on aspects of emergency planning including Pandemic Flu and waterborne hazards. In addition, local exercising of plans always includes a de-brief in which specific training issues are identified and actioned within the service. 6 Significant Incidents Significant incidents involving infection control matters are reported regularly to the Control of Infection Committee. Complaints would also be reported, but no complaints on Communicable Disease matters have been received. Communicable disease incidents April 2009 January 2010 Pandemic Influenza (Influenza A H1N1v) Pandemic flu planning was put into practice this year with the H1N1 flu Pandemic. An outbreak of influenza A H1N1 started in Mexico in April 2009 and spread worldwide, being declared a pandemic in June

26 NHS Shetland Control of Infection Committee Annual Report The local response to the pandemic required refining some of the existing plans to take into account the particular characteristics of this pandemic and local circumstances at the time. A multi-agency Influenza H1N1 table-top exercise was run for the full Emergency Planning Forum in August 2009 to allow participants to examine resources, plans and existing procedures in relation to Influenza A (H1N1). 63 participants from 19 partner organisations attended, included press and local voluntary organisations, and a number of learning and action points were taken back by individual participants and subsequently by the Emergency Planning Forum Executive. August 2009: Single case of Meningococcal Meningitis (B) A young person in Shetland was diagnosed with meningococcal meningitis group B. Appropriate public health measures were taken including prophylactic antibiotics for close contacts. No further cases were identified and the patient made a full recovery. January March 2010 During this period there were a number of reported episodes of individual members of staff being unwell and absent from work with gastro-intestinal illness, likely to be of viral origin. This was in the context of viral gastroenteritis circulating in the community. Infection control procedures were re-inforced, including absence from work until 48 hours symptom free. There were no instances of patients contracting this type of infection whilst in hospital and the cases amongst staff did not constitute an outbreak at any time. Incidents of potential infection risk April 2009: Hot water supply to Breiwick House. The hot water was found not to be reaching the required temperature for the purposes of prevention and control of legionella in the water supply. A temporary solution was put in place when the problem was discovered, and later a permanent solution was made. There were no direct impacts on staff or patients. June 2009: Water supply - Ward 3 A problem was identified with the plumbing in Ward 3. Routine temperature testing of the water (as required for legionella control) showed that the correct temperatures were not being consistently maintained. It was found that the hot and cold water pipes were too close to each other and at the wrong angles - resulting in cold water being warmed up because of the proximity of the hot water pipe and water being able to flow back. Immediate action was taken to minimise any risk to patients and staff, along with increased monitoring, whilst remedial work was carried out to rectify the problem. There were no direct impacts on patient care or clinical outcomes. August 2009: Water supply - Montfield In August 2009 there was a problem identified with the hot and cold water supplies at Montfield. Routine temperature testing of the water (as required for legionella control) showed that the correct temperatures were not being maintained. Immediate action was taken to reduce the risk of legionella (ie no showers) and further investigation undertaken to identify the cause of the problem. There was found to be a problem with the pipework which was rectified. During this period, and after the work had 25

27 NHS Shetland Control of Infection Committee Annual Report been carried out, there was increased frequency of monitoring of the temperatures. Disinfection of the system was carried out after the work had been completed and temperatures monitored until they remained consistently at the correct level. There were no adverse patient outcomes from this incident. December 2009 A flood in the GBH was reported to the Infection Control Team in December but no infection control issues arose from it. 7 References 1 Quality Improvement Scotland. Healthcare Associated Infection Standards Watt B et al: The Watt Group Report. Edinburgh: SEHD, SEHD. Infection Control and Cleaning: Nursing Issues HDL (2005) 7. Available at: 4 SEHD. Infection Control: Organisational Issues HDL (2005) 8. Available at: 5 Healthcare Associated Infection Task Force. The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection. Scottish Executive: Edinburgh, NHS Scotland: Sterile Services Provision Review Group: First Report: The Glennie Framework NHS Scotland, 2001: 7 Healthcare Associated Infection Task Force. The NHS Scotland National Cleaning Services Specification. Edinburgh: Scottish Executive, Available at: 8 Healthcare Facilities Scotland. Monitoring Framework for National Cleaning Services Specification: Guide for NHS Scotland Managers Version 2. National Services Scotland, Available at: 9 Scottish Executive. Preventing infections acquired while receiving healthcare: The Scottish Executive's Action Plan to reduce the risk to patients, staff and visitors. Scottish Executive, Available at: 10 Health Protection Scotland. The Annual Surveillance of Healthcare Associated Infection Report January - December Health Protection Scotland; Glasgow Available at: 11 Scottish Government Health Department. A revised framework for national surveillance of healthcare associated infection and the introduction of a new health efficiency and access to treatment (HEAT) target for Clostridium difficile Associated Disease (CDAD) for NHS Scotland. NHS CEL(2009)11:SGHD;2009. Available at: 12 Public Health etc. (Scotland) Act 2008 available at: Scotland/publicact 13 Source: Information and Statistics Division of NHS National Services Scotland. Data available at the ISD website Scottish Health Statistics (last updated October 2004): 26

28 Appendix A: Surveillance Report Communicable Disease and Infection Control Surveillance For the purposes of this annual report, surveillance data have been presented for the six year period April 2004 March 2010 wherever possible. This is with the aim of providing some indication of monthly and seasonal trends. Unless otherwise stated, all data used in this report is from the NHS Shetland Public Health Department s surveillance systems. 1 Staphylococcus Aureus Surveillance 1.1 MRSA (Methicillin Resistant Staphylococcus Aureus) MRSA is a bacteria carried by many people that can sometimes cause serious infections, particularly in hospital patients. MRSA is generally identified in two ways: Screening of patients (eg on returning from mainland hospitals) Isolating MRSA as a cause of infection (for example a wound swab or urine test) In Shetland, the Public Health Department collects information on MRSA colonisation and infection and reports these to the Control of Infection Committee. We also take part in the national surveillance system for MRSA bacteraemia (a serious blood infection). All patients transferred from hospitals on the mainland to Lerwick hospitals have been routinely screened for MRSA for a number of years. As part of the national MRSA Screening Programme, since January 2010 patients admitted electively to hospital have also been screened. Up until March 2010, patients who were found, on screening, to be colonised with MRSA have been included in the local MRSA figures along with those with infections. However, as surveillance processes have now improved, patients who are colonised but not infected will no longer included in the numbers from March Local surveillance New cases of MRSA colonisation and infection in Shetland Other infection and colonisation Bacteraemia No. of cases Quarter Nationally, the number of new cases has been decreasing in recent years, and local numbers, although remaining small, appear to reflect that trend. 1

29 Appendix A: Surveillance Report National surveillance The Scottish Surveillance of Healthcare Associated Infection Programme produces quarterly reports of MRSA (and now MSSA) bacteraemias across all Scottish NHS Boards since it was started in The Health Protection Scotland reports show that there was one MRSA bacteraemia in MSSA (Methicillin Sensitive Staphylococcus Aureus) This is a common bacterium that can colonise or cause infection in the same way as MRSA, but it is more susceptible to antibiotic treatment. In order to better understand the trends in MRSA bacteraemias and how to reduce incidence, there is now mandatory surveillance of MSSA in addition to MRSA. Numbers in Shetland are small, as for MRSA infections, and since collection of data has only started recently, it is too early to see trends. In the initial reporting phase, we had some difficulties locally in reconciling locally reported figures from those reported nationally. This has been resolved with direct reporting from the laboratory to the public health department, and individual reconciliation of each case, which supports and strengthens local surveillance and any necessary actions. Although 4 MSSA bacteraemia cases were reported in the first quarter of , three of these were from the same patient. There have been no cases in the last three quarters. Local reporting of MRSA and MSSA bacteraemias: Quarter Apr Jun 09 New MRSA bacteraemias New MSSA bacteraemias Jul Sep 09 Oct Dec 09 Jan Mar Total * *Note: 4 new MSSAs reported, though this represents only 2 patients, one of whom had repeated samples taken with a total of 3 testing positive. 2 Clostridium Difficile surveillance The national surveillance programme monitors the occurrence of Clostridium difficle associated disease (CDAD) in all patients aged 65 and over presenting with diarrhoea who have been in contact with the healthcare system. 3 The national reports show that there have been no cases of C difficile included in national surveillance in 2009/10. The locally reported figures include all cases of Clostridium difficle. Local Reporting of CDAD: Quarter Apr Jun 09 No. of new cases C.diff Jul Sep 09 Oct Dec 09 Jan Mar Total Cases are identified through laboratory reports. Numbers in Shetland are again small, and are isolated cases with no outbreaks identified to date. There were no cases in the last three quarters of the year. 2

30 Appendix A: Surveillance Report Surgical Site Infection Surveillance (SSIS) Surgical site infections are one of the most common healthcare associated infections, resulting in an average additional hospital stay of 6.5 days and an additional cost of over The national surveillance scheme has been running since Locally, information is collected on two surgical procedures: fractured neck of femur (broken hip) and emergency caesarean section. Information is collected until the point of discharge for fractured neck of femur and until 10 days post-operatively for caesarean sections. SSIS in Shetland Quarter C Section Procedures C Section Infections Apr Jun 09 Jul Sep 09 Oct Dec 09 Jan Mar Total Rate (%) 0% 66.7% 0% 0% 15.4% Hip Fracture Procedures Hip Fracture Infections Rate (%) 25% 0% 0% 0% 7.7% Total Procedures Total Infections Total Rate (%) 12.5% 40% 0% 0% 11.5% 4 Communicable disease surveillance The Public Health Department is informed of all cases of notifiable disease confirmed by the laboratory and a large number of clinical cases identified by GPs and hospital doctors. This information is forwarded to Health Protection Scotland which produces weekly updates on a national basis. The system for reporting of notifiable diseases changed on 1 st January The list of diseases that doctors should notify has changed, with chickenpox and food poisoning no longer notifiable on clinical suspicion. However, there is now mandatory reporting of a number of organisms that cause infections through the laboratories. The tables below show the quarterly figures for and the annual totals for the five year period

31 Appendix A: Surveillance Report Communicable disease notifications: Quarterly figures for Apr June 2009 July Sept 2009 Oct Dec 2009 Jan - Mar 2010 Chickenpox * Campylobacter Salmonella E.coli Food poisoning (other) * Cryptosporidiosis Measles Mumps Scarlet fever Erysipelas Legionellosis Malaria Hepatitis A Entamoeba histolytica cysts *Note: Since January 2010 chickenpox and food poisoning (other) are no longer notifiable, but the individual micro-organisms that cause illness are these will be reported in detail in next years report. Communicable disease notifications: Annual figures for Chickenpox Campylobacter Salmonella E.coli Food poisoning (other) Cryptosporidiosis Measles** 0 1 unconf Mumps** 63 conf. 2 conf. 1 conf unconf. 3 unconf. 36 neg. Rubella** 2 negative 1 unconf Scarlet fever Whooping cough Erysipelas Legionellosis Malaria Hepatitis A 2 0 Entamoeba histolytica cysts **Notified on clinical diagnosis, confirmed by saliva test (if no test then remains unconfirmed) 4

32 Appendix A: Surveillance Report Measles, mumps and rubella Cases of measles, mumps and rubella are now rare, though occasional cases do occur, and the concern is that low levels of immunisation make the local population prone to an outbreak as has been seen in other parts of the UK. 4.2 Chickenpox Chickenpox continues to be a common childhood infection with a cyclical pattern of infection every two to three years. Note that from January 2010, chickenpox will no longer be reported on clinical suspicion. Chickenpox notifications Year No. notified cases Notifications of Chickenpox April March Number of cases Apr-June 05 July - Sept 05 Oct - Dec 05 Jan -Mar 06 Apr-June 06 July - Sept 06 Oct - Dec 06 Jan -Mar 07 Apr - June 07 July - Sept 07 Oct - Dec 07 Jan - Mar 08 Apr - June 08 July - Sept 08 Oct - Dec 08 Jan - Mar 09 Apr - June 09 July - Sept 09 Oct - Dec 09 Jan - Mar 10 Quarter 4.3 Food and waterborne infections The commonest food and waterborne infection is campylobacter, followed by salmonella and occasional cases of cryptosporidium. Until January 2010, cases of food poisoning were notified by GPs and hospital doctors based on clinical diagnosis, along with diagnosed cases reported by the laboratory. Since January 2010 notification is not required on clinical suspicion except for suspected E Coli. However, all laboratory diagnosed cases of specific infections are reported. Environmental Health is informed of all cases of diagnosed food poisoning (particularly if a commercial food source is implicated). Food poisoning often peaks in the summer due to warmer weather and incorrect storage or cooking of food. 5

33 Appendix A: Surveillance Report Notifications for selected gastro-intestinal infections Apr 05 - Mar 10 Number of notifications Salmonella Campylobacter Cryptosporidium 2 0 Apr- June 05 July- Sept 05 Oct- Dec 05 Jan- Mar 06 Apr- June 06 July- Sept 06 Oct- Dec 06 Jan- Mar 07 Apr- June 07 July- Sept 07 Oct- Dec 07 Jan- Mar 08 Apr- June 08 July- Sept 08 Oct- Dec 08 Jan- Mar 09 Apr- Jun 09 Jul- Sep 09 Oct- Dec 09 Jan- Mar 10 Quarter Campylobacter This is the most commonly notified food borne infection and is commonly associated with undercooked poultry. As can be seen from the table below, the number of cases of campylobacter fluctuates each year, and is generally relatively small. Year No. of notified cases E coli 0157 There have been sporadic cases of E coli 0157 in Shetland over the past few years, but none in Sharps Injuries amongst NHS staff There are clear organisational systems and procedures in place for preventing and managing sharps injuries, but effectiveness is dependant on staff being aware of and following them. Year No. of sharps injuries notified to Occupational Health

34 Appendix A: Surveillance Report Across Scotland the annual incidence of sharps injury is approximately 15 per 1,000 staff. 5 Shetland NHS Board employs approximately 700 staff which gives us a rate for that is slightly above the national average(17 injuries recorded). The annual incidence of sharps is small and appears to have remained relatively stable. Although there has been much work to reduce the incidence of sharps injuries, there is also likely to have been increased reporting by staff. 6 Childhood immunisation Immunisation uptake figures are recorded by quarter and are reported as a percentage of all the children who reached a certain age within that quarter. All the figures below are reported by ISD, using data collected via local systems and entered onto the national database: SIRS, the Scottish Immunisation Recall System month uptake figures are for Diptheria, Tetanus, Pertussis, Polio, Hib (all 3 doses); Meningitis C vaccinations (3 doses before October 2006, now 2 doses) and PCV (2 doses introduced in October 2006). The uptake at 24 months is for MMR (1 st dose), PCV booster (given at 13 months from October 2006) and Hib/MenC booster (given at 12 months from October 2006). The pre-school figures are for completed courses of Diptheria, Tetanus, Polio (4 th dose) and MMR (1 st dose and 2 nd dose) at age 6. Nationally, the reporting of the pre-school figures changed in 2007 so that they are now reported at 5 years. This is to bring Scotland in line with England. 6.1 Primary Immunisations Table 1: Immunisation uptake rate at 12 months Number in cohort Total 2006 Total 2007 Total 2008 Jan- Mar 09 Apr Jun 09 Jul Sept 09 Oct- Dec 09 Total 2009 Jan- Mar Diptheria 94.4% 94.2% 98.4% 97.9% 93.4% 79.5% 75.4% 87.2% 71.7% Tetanus 94.4% 94.2% 98.4% 97.9% 93.4% 79.5% 75.4% 87.2% 71.7% Pertussis 94.4% 94.2% 98.4% 97.9% 93.4% 79.5% 75.4% 87.2% 71.7% Polio 94.4% 94.2% 98.4% 97.9% 93.4% 79.5% 75.4% 87.2% 71.7% Hib 94.4% 94.2% 98.4% 97.9% 93.4% 79.5% 75.4% 87.2% 71.7% Men C* 94.8% 93.5% 97.9% 97.9% 93.4% 79.5% 75.4% 87.2% 75.0% PCV % 97.9% 93.4% 82.2% 75.4% 88.0% 73.3% *Uptake figures for 2 doses from October 2006 (previously 3 doses) The uptake of primary immunisations in Shetland is generally high. The target is to reach a 95% uptake as this is the level at which herd immunity protects those who have not had or are unable to have the immunisation. However it can be seen from the table above that the uptake of primary immunisations by age 12 months has dropped in the past three quarters. This has been investigated and found to be due to problems with the national surveillance system, SIRS. There have been problems with the information on Shetland babies who have had their immunisations being correctly recorded on SIRS. There were 7

35 Appendix A: Surveillance Report also found to be problems with call recall system (two Shetland practices use SIRS for call-recall) meaning that some children were not called by the system at the appropriate time. All the information recorded on SIRS has been checked and any children who were not called at the appropriate time have now been invited Table 2: Immunisation uptake rate at 24 months Number in cohort Total 2006 Total 2007 Total 2008 Jan- Mar 09 Apr Jun 09 Jul Sept 09 Oct- Dec 09 Total Jan- Mar 10 Diptheria 95.7% 97.0% 97.8% 100.0% 96.9% 98.2% 96.6% 98.0% 98.0% Tetanus 95.7% 97.0% 97.8% 100.0% 96.9% 98.2% 96.6% 98.0% 98.0% Pertussis 95.7% 97.0% 97.8% 100.0% 96.9% 98.2% 96.6% 98.0% 98.0% Polio 95.7% 97.0% 97.8% 100.0% 96.9% 98.2% 96.6% 98.0% 98.0% Hib 95.7% 97.0% 97.4% 100.0% 96.9% 98.2% 96.6% 98.0% 98.0% Men C 89.3% 97.0% 96.7% 100.0% 95.4% 98.2% 94.8% 97.2% 98.0% MMR 84.6% 84.7% 84.5% 82.4% 84.6% 89.5% 89.7% 86.6% 85.7% PCVB 79.3% 85.3% 83.1% 91.2% 87.9% 87.0% 89.8% Hib/Men C 79.0% 85.3% 83.1% 61.4% 58.6% 73.6% 61.2% This table shows that by the age of 2 years, a few more children had received their primary immunisations. The uptake for 2009 was 98.0%. The uptake of the PCV booster has now been measured for the past 2 years and it is showing signs of increase to over 87% in the most recent quarters. However, the uptake of the Hib / Men C booster appears to have dropped in recent quarters. This was found to be due to the same problems as the 12 month uptake and all the information recorded on SIRS has been checked and any children who were not called at the appropriate time have now been invited. MMR see below 8

36 Appendix A: Surveillance Report Pre-school immunisations Table 3: Immunisation uptake - Pre-school (full course including boosters) at age 5 years Number in cohort Total 2006 Total 2007 Total 2008 Jan Mar 09 Apr Jun 09 Jul Sep 09 Oct Dec 09 Total Jan Mar 10 Diptheria 77.9% 79.1% 77.2% 83.9% 85.7% 89.4% 86.5% 85.7% 74.6% Tetanus 77.9% 79.1% 77.2% 83.9% 85.7% 89.4% 86.5% 85.7% 74.6% Pertussis 77.9% 79.1% 77.2% 83.9% 85.7% 89.4% 86.5% 85.7% 74.6% Polio 77.9% 78.6% 76.8% 83.9% 85.7% 89.4% 86.5% 85.7% 74.6% MMR: 2 doses 54.5% 65.4% 64.6% 74.2% 76.2% 78.8% 84.6% 77.6% 70.1% MMR: 1 dose* 86.2% 91.9% 92.7% 98.4% 93.7% 93.9% 98.1% 95.5% 89.6% * this was a new measure introduced for monitoring the HEAT target for MMR update (based on WHO target for 95% at 5 years for 1 st dose MMR) No longer included as HEAT target for 2008/09. Table 4: Immunisation uptake - Pre-school (full course including boosters) at age 6 years Number in cohort Total 2006 Total 2007 Total 2008 Jan- Mar 09 Apr Jun 09 Jul Sept 09 Oct- Dec 09 Total Jan- Mar 10 Diptheria 90.0% 85.3% 91.6% 80.0% 91.2% 88.7% 95.5% 88.6% 93.8% Tetanus 90.0% 85.3% 91.6% 80.0% 91.2% 88.7% 95.5% 88.6% 93.8% Pertussis 90.0% 85.3% 91.6% 80.0% 91.2% 88.7% 95.5% 88.6% 93.8% Polio 90.4% 84.9% 91.6% 80.0% 89.7% 88.7% 95.5% 88.6% 93.8% MMR: 2 doses 71.6% 67.7% 80.2% 74.3% 80.9% 84.5% 88.6% 82.0% 90.8% These tables show that there is generally a fairly low uptake of the pre-school booster (given that the uptake of the primary immunisations is high). In % of 5 year olds and 88% of six year olds had completed their boosters. 6.3 MMR Uptake of first dose of MMR at two years is showing a slow upward trend but has not yet reached the 95 % target for herd immunity. As can be seen from the graph below, MMR uptake continues to rise gradually, with an increase from 50% at the beginning of 2003 now up to 85.7% by the end of This reflects the anecdotal reports that uptake has improved over the past few years. The overall uptake of 1st dose MMR at 24 months for 2009/10 was 87.7% compared to 83.6% in 2008/09. 9

37 Appendix A: Surveillance Report However analysis of the figures show the number of children who receive a first dose MMR does increase with age: in 2009, 95% of children reaching the age of five had received their first MMR. As in previous years, there appear to be a number of parents who delay vaccination until their child is nearer three or four years of age. These children are therefore not picked up in the 24 month uptake figures. The cohort of children who had their second birthday during 2006 are the same cohort who turned five in As can be seen from the figures above, only 84.6% of these children had their 1 st MMR by age 2 but the uptake had increased to 95.5% by the time they were five. nd The uptake of the 2 dose of MMR is still low, with a slight upward trend. We know that some of these children have their first MMR late and so may not get round to having their second MMR before they are six, if ever. We are trying to reduce this problem by encouraging the second MMR vaccination at 1-3 months after the first in this group of children. As there are now more children having their first MMR before the age of two, this should eventually be reflected in an increased number having two doses before they go to school. In the meantime, children who have only had one dose may be unprotected. There are still a number of families who refuse MMR (sometimes all vaccinations) and these appear to be concentrated in certain areas of Shetland. When parents have very fixed views on vaccinations, there is very little that we can do to persuade them to change their beliefs. However, where parents are unsure or ambivalent about vaccination then healthcare staff can help them to make an informed decision based on good scientific evidence. Uptake of MMR at 24 months by quarter % uptake Shetland Scotland Target 10 0 Apr - July - Jun 06 Sep 06 Oct - Dec 06 Jan - Mar 07 Apr - Jun 07 Jul - Sept 07 Oct - Dec 07 Jan - Mar 08 Apr - Jun 08 Jul - Sept 08 Oct - Dec 08 Jan - Mar 09 Apr - Jun 09 Jul - Sept 09 Oct - Dec 09 Jan - Mar 10 Quarter 7 HPV Vaccination programme The HPV vaccination programme commenced in September All girls in secondary school year S2 are invited to have the vaccination through a schools based programme. The full course consists of three vaccinations over a six month period. In addition, all girls who were above S2 but younger than 18 at the beginning of the programme have been invited for the vaccination as part of a catch up programme. During 2008/09 this included all girls in S5, S6 and those who had left school. In this included girls in S4 and S5. 10

38 Appendix A: Surveillance Report Table 5: Uptake of three doses of HPV vaccine in (school year) 2008/09 Shetland Scotland Girls in S2 93.2% 91.4% Girls in S5 90.8% 89.9% Girls in S6 89.7% 86.6% Girls who have left school 53.9% 31.8% All girls in school: S2,S4 and S5 91.5% 89.8% All girls in catch up 73.9% 59.7% The uptake in Shetland was consistently higher than across Scotland as a whole. The girls who had left school were a harder to group to identify and to invite for their vaccinations. It is likely that many of the girls invited in Shetland have moved away south. The figures for 1009/10 are not yet complete as the data on uptake of the third dose of vaccine, and delayed second doses, is not yet available. Table 6: Uptake of two doses of HPV vaccine in (school year) 2009/10 - as at February 2010 Shetland Scotland Girls in S2 84.1% 85.8% Girls in S4 90.6% 79.7% Girls in S5 74.4% 80.0% All girls in school: S2,S4 and S5 83.2% 81.9% 8 Influenza vaccination 8.1 Seasonal flu vaccination Influenza vaccination is offered on an annual basis each autumn / winter to all those aged 65 and over and to those younger adults and children who are in high risk groups (eg with certain medical conditions). Vaccination uptake in the 65+ age group is monitored and reported each year. The national target was 70% in 2009/10, but for 2010/11 it is being increased to match the World Health Organisation target of 75%. There is also monitoring of the at risk groups, but this is more difficult to interpret as some patients may fall into more than one group. During the season, the uptake amongst over 65s across Scotland was 75.0%. The graph below shows the uptake amongst individual GP practices in Shetland. 11

39 Appendix A: Surveillance Report Percentage Flu Vaccine Uptake (65+) 2009/10 Uptake Target Practice (anonymised) 8.2 Pandemic flu (Influenza A H1N1) vaccination Influenza A H1N1 vaccination was offered to a number of groups of people as part of the response to pandemic flu. In Phase 1, all patients in the seasonl flu clinic risk groups were offered the vaccination, along with all pregnant women, household contacts of immunosuppressed patients; and front line health and social care staff. In phase 2, all children aged 6 months to five years were offered the vaccine. In addition, poultry workers were offered the vaccine. People aged over 65 without any clinical risk factors and carers were not routinely offered H1N1 vaccination (unlike seasonal flu). The Health Protection Scotland Influenza Report in March 2010 estimated that, for the whole of Scotland, : the cumulative uptake rate among individuals aged less than 65 in a clinical at risk group (including pregnant women), was 54.3%. the cumulative uptake rate among individuals aged 65 and over in a clinical at risk group was 56.1%. the overall uptake for individuals in a clinical at risk group was 55.1%. the uptake rate in pregnant women was 47.6%. However there were problems with recording of the denominator (ie the number of women eligible). Locally collected uptake figures showed slightly higher rates. In total, in Shetland over 5500 people received the vaccination. 9 References 1 Quarterly reports on the surveillance of Staphylococcus aureus bacteraemias in Scotland: 2 Health Protection Scotland. The Annual Surveillance of Healthcare Associated Infection Report January - December Health Protection Scotland; Glasgow Available at: 3 Quarterly reports on the surveillance of Clostridium Difficile Infections (CDI) in Scotland 4 SSHAIP. Surveillance of surgical site infection for procedures carried out from 1/04/02 30/06/06. Glasgow: HPS, Available at: 12

40 Appendix A: Surveillance Report Source: Information and Statistics Division of NHS National Services Scotland. Data available at the ISD website Scottish Health Statistics (last updated October 2004): 6 Source: Information and Statistics Division of NHS National Services Scotland. Data available at the ISD website Scottish Health Statistics (last updated 24 th June 2010): 13

41 Control of Infection Committee: Work Programme (Incorporating the Training and Audit Programmes) Work Programme Action Responsibility Timescale / progress 1 Surveillance Overall Responsibility: Director of Public Health (ST) 1.1 Healthcare Associated Infection MRSA (local surveillance) Public Health ( SL) (Quarterly reports) MRSA & MSSA bacteraemia Laboratory (IH) Use of SAB form Senior Charge Nurses / Infection Control Nurse (TB-I) Surgical Site Infection Surveillance (SSIS) Theatre staff / Public Health (KGo) Clostridium difficile Laboratory (IH) Patient safety programme Scottish HAI Outbreak Online Reporting System (SHORS) Public Health (SL) / SPSP Programme Manager (Colin Bell) Public Health (SL / ST) Implement use of CDAD Trigger Tool Public Health (SL/ST) / Infection Control Nurse (TB-I) Implement use of Severe CDAD Investigation Tool Public Health (SL/ST) / Infection Control Nurse (TB-I) MRSA Screening Surveillance Public Health ( SL) / laboratory (LP) / POA Unit (Margaret Cooper) 1.2 Communicable disease surveillance (including immunisation uptake) 1.3 Sharps injuries (Including investigation of increase in sharps injuries in any clinical area) Public Health (David Kerr /KGo /SL) Occupational Health (BD) (Quarterly reports) (Quarterly reports) 1

42 Work Programme Training (part of and in line with Board Training Plan) see detailed plan at end Overall Responsibility: Infection Control Manager 2.1 Awareness raising and publicity for infection control training and useful resources through Staff Development Bulletin Staff Development (MH)/ SL (Quarterly bulletins) 2.2 Incorporation of infection control into all training run by Staff Development Staff Development (AG) / Infection Control Nurse (TB-I) 2.3 Induction & refresher days for NHS staff including infection control food handling training for clinical staff (LearnPro module) 2.4 Infection control training delivered through SHO Educational Programme; Postgraduate Education Programme and for medical students. Staff Development (AG & Staff Development Team) / rota of all members of ICT Staff Development (AG / Andrew Humphrey) Infection Control Nurse (TB-I) / Public Health (ST) (monthly) (monthly) 2.5 CDU staff training CDU Manager (CC) 2.6 SSIS training Public Health (WH) /Infection Control Nurse (TB-I)/ SSHAIP TBA 2.7 IV drug infusion training Staff Development/ Public Health Nurse (WH) 2.8 Cleanliness Champions (NES on-line package) Staff Development (HW) / Infection Control Nurse (TB-I) 2.9 Hand Hygiene Education Package (on-line) Staff Development (publicity through Staff Development Bulletin see 2.1) / Individual staff (PDPs) 2.10 Other NES on-line packages Staff Development (publicity through Staff Development Bulletin see 2.1) / Individual staff (PDPs) 2

43 Work Programme Continuation of hand hygiene educational sessions (including skin care) Local Board Hand Hygiene co-ordinator (Infection Control Nurse (TB-I)) / Staff Development (admin & publicity MH) 2.12 FFP3 Fit testing H&S Manager (Catriona Oxley) / Asst Director Nursing Hospital (JM) (new staff) 2.12 Infection Control Team: individual PDPs and training programmes ST / SL / EMW / JM / TB-I / WH / KC/BD HPS/NES Immunisation on-line training (Promoting Effective Immunisation Practice) Local Immunisation update training Immunisation Co-ordinator (SL) / Immunisers Immunisation Co-ordinator (SL) / Staff development (admin & publicity MH) Due in March 2011 (annual) 2.15 HAI SCRIBE Training (if national training becomes available if / when revised SCRIBE is published) 2.16 Training in use of the new decontamination unit (for CRBN incidents) when installed Infection Control Team / Head of Estates (JMB) A&E staff (Lynda Smith) / Estates / Emergency Planning Officer (John Taylor) TBA TBA 3 Policy & procedure development : Infection control in healthcare setting Overall Responsibility: Infection Control Manager 3.1 Ensure all new policies marked with review date Infection Control Nurse (TB-I) 3.2 Ensure assessment of all policies against Equality and Diversity Impact Assessment Toolkit Infection Control Nurse (TB-I) (existing policies)/ authors of each individual policy (new policies) 3.3 Continue to update infection control procedures against national guidance Infection Control Nurse (TB-I) as required 3

44 Work Programme Development of Local Antibiotic Policy (Local variations to Grampian Policy) Antimicrobial Management Team (Catriona Innes) TBA Public Health / Outbreaks Overall Responsibility: Director of Public Health (ST) 3.7 Generic Public Health Outbreak / Incident Plan Public Health (SL) August Local Meningitis Plan Public Health (SL) December 2009 slipped to Aug Legionnaires disease procedures (to complete) Public Health (SL) / Environmental Health Service Manager (MD) December 2009 slipped to Aug CRBN / deliberate release incidents- local plan Joint Health Protection Plan NEW Public Health (ST) / Environmental Health Service Manager (MD)/ Emergency Planning Officer(John Taylor) Public Health (ST/SL) & Environmental Health Service Manager(MD) December 2009 slipped to Aug 10 April completed 4 Prevention of HAI: Decontamination Overall Responsibility: Infection Control Manager (NF) 4.1 Implementation of Business Case for Dental Services Director of Clinical Services (Simon Bokor-Ingram) / CDU (CC) TBA 5 Prevention of HAI: Task Force Delivery Plan Overall Responsibility: Infection Control Manager (other actions picked up elsewhere in Work Plan) 5.1 Continued Implementation of Hand Hygiene programme Local Board Hand Hygiene Co-ordinator (Infection Control Nurse (TB-I)) 5.2 Continue Cleanliness Champions programme Infection Control Nurse (TB-I)/ Staff Development (HW) 4

45 Work Programme HAI incident and near miss reporting; raise awareness and implement risk matrix. Infection control risks and incidents to be reported to CoIC quarterly Risk and Incident Co-ordinator (Scott Miller) / Infection Control Team 5.6 Monitoring of Hospital Cleaning Standards General Services Co-ordinator (MF) (Quarterly reporting to CoIC) 5.7 Action to achieve HEAT target: to reduce SA bacteraemias (including surveillance; implementation of procedures; patient safety bundles) All members of Infection Control Team 5.8 MRSA Screening Public Health (SL) / Pre-operative assessment service (Margaret Cooper) / Laboratory (LP) 6 Prevention of HAI: HAI Action Plan (Vale of Leven) Overall Responsibility: Infection Control Manager 6.2 Reporting 2 monthly Board reports Infection Control Manager 7 Prevention of HAI: Integrated HAI Action Plan Overall Responsibility: Infection Control Manager Develop a monthly report from the ICT for all clinical teams Ensure clinical HWB installed as per SHFN 30 v3 Clarify & communicate senior nurse / H&S manager / Asst Director Nursing roles in relation to HAI and general hospital management Infection Control Manager (KC) / Infection Control Nurse (TB-I) Head of Estates (JmB) Head of Estates (JmB) Review Aug Regular walk-arounds undertaken by senior managers Senior Managers / Assistant Director of Nursing (Hospital) (JM) / Head of Estates (JmB) CE monthly DCS & NMAHP 5

46 Work Programme every two weeks ADN (Hospital) & HoFE - weekly 7.7 Introduce Estates User Forum quarterly to enable discussion about HAI and facilities issues 7.8 Performance management of individuals by managers including objective setting Head of Estates (JmB) Review Aug 2010 All Senior Managers Review Aug Organisational lead from CE through SMT on expectations, priority of HAI, follow-up of poor performance demonstrated through: Team briefs Walk arounds Management of poor performance Zero tolerance 7.10 Take forward the patient safety programme methodology as set out in the iiip Chief Executive (Sandra Laurenson) Infection Control Manager (KC) / Infection Control Nurse (TB-I) Review Aug Agree the timeline and priorities set against completion of capital works to Ward 3 sluice area, renal and maternity departments as part of the HAI related capital improvements. Head of Estates (JmB) Review Aug Ensure that training and learning outcomes in relation to HAI are standardised and included in: Mandatory training Corporate induction Infection Control Manager (KC) / Infection Control Nurse (TB-I) Review Aug

47 Clinical area level induction New start checklists for HCSWs Waste management training for all clinical staff Root cause analysis as part of HAI outbreak investigations and incident cases of positive SAB/CDifficle Facilities Manager (MF) Work Programme Pandemic Flu Planning Overall Responsibility: Director of Public Health (ST) 8.1 Further updating of plan in line with national guidance Pandemic Flu co-ordinator (SL) 8.2 Further exercising of plans depending on current situation Pandemic Flu co-ordinator (SL) / Emergency Planning Officer (John Taylor) 9 Audit Projects (see detailed plan at end) Overall Responsibility: Infection Control Manager 9.1 Hand hygiene audit as part of national campaign Local Board Hand Hygiene Co-ordinator (TB-I) ongoing 9.3 Hand gel use ICN (TB-I) TBA 9.4 Monthly Cleaning Facilities Manager (MF), ICT rep, Lay member Monthly ongoing 9.5 HAI General Audit 9.6 MRSA Screening Programme ICM / Director of Clinical Services (Simon Bokor Ingram) / Medical Director (KG) / ICN (TB-I) / ICT (rota) Public Health (SL) Monthly different areas on rolling basis August Hospital Capital Plan Ensure infection control issues addressed within plans Overall Responsibility: Head of Estates (JMB) Infection Control Team / Estates / Project Manager December

48 for building works including: Design of clinical areas New fixtures, fittings & equipment Appropriate infection control measures during building works Reports to CoIC (NB also national work on Estates, Facilities & Environment as part of HAI Taskforce Delivery Plan & QIS standards) Repeat HAI SCRIBES after works completed (Lawson Bisset) Infection Control Team / Estates / Project Manager (Lawson Bisset) Work Programme As required 11 Control of Infection Committee Produce Annual Report and present to Clinical Governance Committee Overall Responsibility: Chair of CoIC (ST) CoIC (ST) By June Patient Focus Public Involvement Overall Responsibility: Infection Control Manager (NF) 12.1 Increase public involvement in policy & procedures development and review Infection Control Nurse (TB-I) / Cleanliness Champions 12.2 Develop & disseminate HAI information to the public, patients, families & carers Infection Control Nurse (TB-I) / Cleanliness Champions 12.3 Increase public involvement in cleanliness monitoring & hand hygiene Infection Control Nurse (TB-I) / Cleanliness Champions 8

49 Control of Infection Training Programme: April March 2011 Resources identified, and recording, reporting & evaluation via Board s Training Plan Work Programme Action Responsibility Timescale 1 General Awareness raising and publicity for infection control training through Staff Development Bulletin Incorporate infection control into all training run by Staff Development Staff Development (MH)/ SL Staff Development (AG) / Infection Control Nurse (TB-I) (Quarterly bulletins) All staff have HAI CPD objectives included within PDPs Line managers 2 Induction & refresher days for NHS staff Staff Development (AG & Staff Development Team) Induction for all Board Staff Provide session on infection control Mandatory Refresher Days Provide session on infection control LearnPro on-line training module -HAI LearnPro on-line training module food hygiene 3 Infection control training for doctors Rota of all members of ICT Rota of all members of ICT Staff Development (AG / Andrew Humphrey) Staff Development (AG / Andrew Humphrey) (monthly) (monthly) 9

50 Work Programme SHO Educational Programme session on infection control Public Health (ST / WH) / TB-I (Approx quarterly) Postgraduate Education Programme - IC session offered Public Health (SL /ST / WH) / TB-I As required Medical students infection control session offered Public Health (SL /ST / WH) / TB-I As required 4 CDU staff training NVQ in decontamination (level 3) for operators CDU Manager (CC) MSc in Medical Devices Decontamination for CDU Manager (dissertation) CDU Manager (CC) 2010/11 Other relevant training CDU Manager (CC) 5 SSIS training Training for staff involved in completing SSIS forms and administering the system 6 IV drug infusion training Infection Control input to drug infusion training 7 Cleanliness Champions NES training package for All registered nurses All registered AHPs other nursing staff and other disciplines 8 Hand Hygiene Education Package Stand alone on-line training package; aimed at all members of staff (clinical) not already doing Cleanliness Champions course. Public Health (WH) /Infection Control Nurse (TB-I) / SSHAIP Staff Development/ Public Health Nurse (WH) Co-ordinated through Staff Development (HW) 10 HW/ EMW/ JM AHPs Staff Development (HW) Staff Development (publicity through Staff Development TBA

51 Bulletin see 2.1) / Infection Control Nurse (TB-I) Individual staff (PDPs) Work Programme Other NES short courses MRSA scenario Clostridium difficile: a clinical scenario Helping patients cope with isolation in hospital Preventing Catheter Related Blood Stream Infections Needlestick Injury: a Clinical Scenario Prevention and Management of Pressure Ulcers Bacterial Resistance : an on-line tutorial Legionella: A Clinical Scenario (pending release) MRSA Screening Other short courses 10 Continuation of hand hygiene educational sessions (including skin care) Sessions for departments and wards on request Staff Development (publicity through Staff Development Bulletin see 2.1) / Infection Control Nurse (TB-I) Individual staff (PDPs) Local Board Hand Hygiene coordinator (Infection Control Nurse (TB-I)) / Staff Development (admin & publicity MH) 11 FFP3 mask fit testing for new clinical staff on induction H&S Manager (Catriona Oxley) / Asst Director Nursing Hospital (JM) (new staff) 11

52 Work Programme Infection Control Team: individual PDPs and training programmes ST / SL / EMW / JM / TB-I / WH / KC / BD DPH & Consultant in Public Health Appropriate CPD ST / SL Public Health Nurse Continue with PhD (on Hepatitis C) WH CDU Manager / Infection control nurse Continue MSc in Decontamination of Medical Devices CC Infection Control Manager Training for ICMs - being developed nationally KC Assist. Directors of Nursing & Snr Occupational Health Nurse Appropriate CPD Infection Control Nurse To be agreed on appointment, dependant on previous experience and training 13 Immunisation on-line training HPS/NES Immunisation on-line training (Promoting Effective Immunisation Practice) 14 Local Immunisation update training Delivery of half day session for immunisers JM / EMW / BD TB-I Immunisation Co-ordinator (SL) / Immunisers Immunisation Co-ordinator (SL) / Staff development (admin & publicity Mark Henry) Due in March 2011 (annual) 12

53 15 HAI SCRIBE Training If national training becomes available if / when revised SCRIBE is published 16 Training in use of the new decontamination unit (for CRBN incidents) when installed Infection Control Team / Head of Estates (JMB) A&E staff (Lynda Smith) / Estates / Emergency Planning Officer (John Taylor) Work Programme TBA TBA 13

54 Control of Infection Audit Programme: April March 2011 Work Programme Audit type Date Location Auditor Hand Gel Audit TBA All ward areas ICN (TB-I) Monthly Cleaning Audits Monthly - ONGOING All ward areas Facilities Manager (MF) / ICT rep / Lay member HAI General Audit Frequency TBA depending on baseline Ward 1 Ward 3 Maternity Ronas Ward ICM / Director of Clinical Services (Simon Bokor Ingram) / Medical Director (KG) / ICN (TB-I) / ICT (rota) Outpatients Renal Unit Day Surgery Unit ICN (TB-I) / ICT (rota) Accident and Emergency Theatre IPU Physiological Measurements Physiotherapy ICN (TB-I) / ICT (rota) Medical Imaging Orthotics Laboratories Audiology 14

55 Work Programme Mortuary Occupational Therapy Reception Changing Rooms Porters room Laundry ICN (TB-I) / ICT (rota) MRSA Screening Programme August 2010 All relevant clinical areas Public Health (SL) 15

56 KEY: Work Programme AC Ailsa Clews* Sodexo Manager EMW Edna Mary Watson* Assistant Director of Nursing (Community) CC Carol Colligan CDU Manager HW Helen Wisdom Clinical Development Facilitator TB-I Tina Bokor Ingram* Infection Control Nurse SSHAIP Scottish Surveillance of Healthcare Associated Infection Programme KC Kathleen Carolan* Director of Nursing / Infection Control Manager BD Bernadette Dunne* Senior Occupational Health Nurse MD Maggie Dunne* Head of Service Environmental Health (SIC) MF Magnus Flaws* Facilities Manager KGo Kim Govier Public Health Secretary AG Andy Glen Staff Development Manager KG Ken Graham* Medical Director WH Wendy Hatrick* Public Health Nurse IH Ian Henderson Head of Laboratory Services MH Mark Henry Staff Development administrator SL Susan Laidlaw* Consultant in Public Health Medicine JMB John McBeath* Head of Estates JM Janice McMahon* Assistant Director of Nursing (Community) LP Les Phipps* Laboratory Quality Manager ST Sarah Taylor* Director of Public Health * Member of Control of Infection Committee 16

57 Media Statement Monday 2 February 2010 HEI Inspection Report: Gilbert Bain Hospital, NHS Shetland Requirements 1. NHS Shetland must ensure that there is effective communication between the infection control team and staff to ensure staff are fully aware of audit results and surveillance data and how they should be interpreted and used. 2. NHS Shetland must review its Service Level Agreement with NHS Grampian to include gathering and reviewing infection control information for patients who are treated by NHS Grampian on behalf of NHS Shetland. 3. NHS Shetland must ensure that clinical sinks of the appropriate dimensions are readily available in all clinical areas in line with national guidance. 4. NHS Shetland must ensure that the appropriate ratio of beds to clinical sinks is available in all clinical areas in line with national guidance. 5. NHS Shetland must review the patient equipment cleaning schedules to ensure that responsibility for the cleaning of patient equipment is clearly assigned to a defined staff group. Recommendations 1. It is recommended that NHS Shetland ensures that it has adequate measures in place to demonstrate that general environmental audits are undertaken on a frequency which is appropriate to the risks identified. 2. It is recommended that NHS Shetland ensures that the renal unit is provided with an appropriate number of clinical waste bins. Healthcare Environment Inspectorate is part of NHS Quality Improvement Scotland