NHS Tayside INFECTION CONTROL. Infection Prevention and Control Scorecard Strategy 2009/10. Information for Clinical Groupings including CHPs

Transcription

1 NHS Tayside INFECTION CONTROL Infection Prevention and Control Scorecard Strategy 29/ Information for Clinical Groupings including CHPs Author: Gabby Phillips Review Group: Infection Control SMT Review Date: June 2 Last Update: June 29 Document No: Issue No: UNCONTROLLED WHEN PRINTED Signed: Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Executive Lead (Authorised Signatory) Page of 47

2 Contents Page number. Summary 3 2. Background 3 3. Aims 3 4. Objectives 3 5. The Scorecard 4 6. Goals for each scorecard target area from January What Clinical Groups Need to Do 8 8. Areas for Scorecard Monthly Monitoring of Wards and Aggregated Groupings 9 APPENDIX : Scorecard May 29-7 APPENDIX 2 - SGHD HAI Action Plan RAG Report (June 29 Response) 8-22 Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 2 of 47

3 . Summary The Healthcare Associated Infection (HAI) Strategy will incorporate the key priority areas as outlined in the balanced scorecard. Clinical groupings including CHPs will receive scorecards on a monthly basis along with access to the raw data, clearly marked with their position and goal. A balanced scorecard will be to achieve 'green status' in all areas. The finding of amber or red will trigger a response for investigation and action. The Infection Control team will support staff to help find solutions. The Divisions Joint Clinical Boards are asked to review progress with the National & HEAT targets : Zero tolerance for hand hygiene compliance in all staff groups Staph aurerus bacteraemia reduced to 46 new episodes for NHS Tayside by the end of March 2 Clostridium difficile reduction (3% by 2 from.64 to.7 episodes per Total Occupied bed days) by 2 Progress is monitored monthly by the Waiting Times performance group, Delivery Unit Management team, Acute delivery Unit Clinical Governance Group, the Board and the HAI Network meetings 6 times per year. In addition figures are scrutinised by Taystat, Chairman s meeting with the SGHD, local Clinical Governance/Risk Management meetings in CHPs. Data are presented at Board meetings and available to the public. Please check: are you. receiving the relevant data? If not please contact Infection Control Office sending the relevant data? (non returns are scored as red) 3. reviewing the HEAT and National HAI Targets and progress regularly? 4. taking actions and monitoring outcomes as needed? Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 3 of 47

4 2. Background The HAI agenda is wide ranging and often complex. It underpins many activities in every area of healthcare from management to hands-on healthcare, and includes clinical and non-clinical staff. NHS Tayside has a single combined delivery of the infection control service across primary and secondary care. Because of the wide ranging remit, focus is on 'high impact' areas where there are good data, surveillance systems and opportunities for interventions that will lead to measurable improvements in place. Other areas and issues will continue to be worked up and managed as listed in the HAI Annual Programme/Improvement Plan. All Clinical groupings including CHPs will still be subject to audits and are expected to continue with their own HAI Action Plans. 3. Aims The aims of the HAI strategy are to continue to improve the health and safety of staff, patients and visitors sustain those improvements that have already been made meet the Nationally set targets for C difficile cases, hand hygiene and staphylococcal bacteraemia and antimicrobial prescribing as well as our locally set targets for other key areas 4. Objectives to meet national HAI and HEAT targets to met local HAI targets to reduce HAI in NHS Tayside with high impact interventions in key high risk areas to engage clinical staff in these improvement goals to produce a format which is simple and easily understood, reproducible to continue improvements across the single delivery unit healthcare sites Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 4 of 47

5 5. The Scorecard 2 3 Hand Hygiene compliance Antimicrobial Prescribing Sharps Injuries HAI S aureus bacteraemias 4 SSI Education VAP 5 Environmental Cleaning CVC associated infections New MRSA acquisition New C. difficile acquisition Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page of 47

6 Beneath each area will be some or all of the following: Goal definition, data collection, display frequency and analysis, bundles, management and reporting systems, policy, procedures, education, training, audit, surveillance, action plans and various groups that work on improvements. For each domain an 'NHS Tayside Good Practice Guideline' is available on request form the infection control office (3238). Non returns of information will be defaulted to 'red'. For clinical groupings including CHPs where areas are amalgamated, the lowest/worst result will be the one submitted (ie if 4/6 wards have achieved green, has achieved yellow and is red, it will be the red one that is put forward for the scorecard). HAI = Healthcare Associated Infection VAP = Ventilator Associated Pneumonia SSI = Surgical Site Infections CVC = Central Venous Catheter For S.aureus bacteraemia, new MRSA acquisition and new c.difficle acquisition the data for acute clinical groupings will be amalgamated and presented as run charts with individual ward or department data presented in table format with status highlighted as red, amber or green. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page of 47

7 6. Goals for each Scorecard Target Area from January 29. Zero tolerance to non compliance with Hand Hygiene standards. Audits performed on monthly samples of 2 staff made up of nurses, 3 medical staff, 4 Allied Health Professionals, 3 ancillary staff. The monitoring is based on the 'WHO 5 points' and on technique using existing tools. > 95% compliance = green < 95% compliance = red Wards will supply data monthly to Infection Control Teams using the data they already collect for the SPSP programme where possible. This needs to be with the Infection Control Office by the 7 th of each month. 2. (i) Orthopaedics arthroplasty prophylaxis compliance with 3 dose regimen. 95-% compliance = green 8-94% compliance = yellow <8% compliance = red Surveillance ICN to provide prophylaxis data. (ii) Compliance with empiric antibiotics policy: Medicine NW, Medicine PRI, Surgery NW, Surgery PRI, RVH - based on compliance data collection by pharmacists in acute admission areas and RVH wards. 95-% compliance = green 8-94% compliance = yellow <8% compliance = red (iii) Compliance with empiric antibiotic policy: PRI and Stracathro MfE wards based on restricted antibiotic usage as a % of total usage -% = green - 5% = yellow >5% = red Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 2 of 47

8 (iv) CHP, Critical Care and Haematology/Oncology indicators to be developed in due course. Boxes will remain blank until then. 3. Number of Sharps injuries per clinical grouping/chp is reduced. (this includes needlesticks and other injuries) = green = yellow 2 = red Results will be taken from Adverse Incident Management data base of electronically reported incidents collated by Infection Control Team % by 2 in Hospital Acquired S aureus bacteraemias (MSSA & MRSA) from March 26 to 46 episodes per annum by March 2. We need to reduce by 5 episodes over the coming year to achieve this target episodes per month per ward = green episode per month per grouping = red Ward/unit/hospital acquired if patient in ward >48 hours from date of blood culture positive sample. 'Back allocation' will be performed if <48 hours from admission to date of positive blood culture. Infection Control Team (ICT) will supply data monthly 5. a) Ventilator Associated Pneumonia rates to be reduced* <5/ ventilator days = green 6-29/ ventilator days = yellow >3/ ventilator days = red ITU will supply data monthly (Dr Sally Croft/Dr I Mellor for NW) OR b) Surgical Site Infection rates to be reduced Breast* <4.9% (green) 5-6.9% (yellow) >7% (red) Caesarean section*, total abdominal hysterectomy* and fractured neck of femur* <4.9% (green) 5-9.9% (yellow) >% (red) Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 3 of 47

9 Total hip and total knee replacements * <.5% (green).6-4.9% (yellow) >5% (red): {deep infections <.5% } Vascular <9.9% (green) -4.9% (yellow) >5% (red) *includes post-discharge surveillance Supply of data as per current surveillance system OR c) Education. Number of Cleanliness Champions on the Ward per month* >4 Champions on ward = green 3 Champions on ward = yellow < 2 Champions on ward = red Mrs F Main will provide data on a monthly basis. *These data need to be with the Infection Control Office by the 7 th of each month 6. Environmental cleaning. Areas to be in green zone using the Domestic Services Monitoring Tool. Domestic services will alert any red or amber in the groupings given below per month. Data will be provided by Chris Gordon, Elizabeth Proudfoot and Billy Thomson. These data need to be with the Infection Control office by the 7th of each month. If results are anything but green the Infection Control team will liaise with Domestics Services for further action and a discussion at the next Performance meeting 7. Central Venous Catheter infection rates to be reduced in the following areas Renal (RDU/22), Surgery (7-2/HDU), Ward 2,Haematology/oncology. < 3/ catheter days = green / catheter days = yellow >4/ catheter days = red Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 4 of 47

10 Supply data monthly as per current systems These data need to be with the Infection Control Office by the 7 th of each month Any other area is welcome to put forward data that they are collecting for this 8. Reduce new MRSA acquisitions, recorded per Month per Ward in line with trigger tool and SGHD new reporting template new cases = green 2 new cases in any ward = yellow > 3 new cases in any ward = red All wards with overnight stay in groups as below based on current local screening policy. In groups of more than one ward, the highest ward score will be the one put forward for the scorecard. Ward acquired if patient has been in unit >48 hour prior to first detection. Back allocation done on basis of knowledge of MRSA status of the last ward/unit/hospital patient was in within past month as per current system ICT will supply data monthly 9. Reduce new C. difficile acquisitions, recorded per Month per Ward in line with trigger tool and SGHD new reporting template new cases = green 2 new cases in any ward = yellow > 3 new cases in any ward = red Wards with overnight stay in groupings as below based on current testing protocol. Ward acquired if patients has been in >48 hours prior to onset of symptoms Back allocation done on basis of knowledge of Clostridium difficile status of the last ward/unit/hospital patient was in within past three months as per current system ICT will supply data monthly Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 5 of 47

11 . Compliance with PVC Bundle, CVC Maintenance Bundle & CVC Insertion Bundles > 95% compliance = green 8 94% compliance = yellow < 79% compliance = red Testing = white Data provided by Diane Campbell s team These data need to be in the Infection Control Office by the 7 th of each month. Alert conditions, Organisms that are reported within 24 hours to ICT/the total number identified % = green 49-99% = amber >5% = red 2. Environmental audits feedback. The number of audits fed back within the agreed timescale >95% = green 49-94% = amber <5% = red 7. What Clinical Groups Need to Do You will receive the following data from the Infection Control Team for monitoring purposes:. New cases of MRSA and Clostridium difficile (HEAT target) for individual wards. The trigger is 2 or more new cases within the previous 3 days. Weekly data are supplied to wards, managers and senior clinical staff. Please distribute as you see fit, remembering your junior medical staff. Infection Control will help support and investigate any triggers and work with you on any remedial actions. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 6 of 47

12 These are supplied weekly and monthly and it is expected that they will be reviewed at your local Clinical Governance meetings or other relevant meetings to ensure that the National and HEAT targets are met. A chart of weekly snapshot of unisolated cases is circulated. 2. Scorecards. To give an overall picture of how your clinical grouping fits in to the NHS Tayside picture and to ensure a balanced approach is taken to the wider aspects of HAI. 3. Staphylococcal bacteraemia (HEAT target) All cases will have a rapid review by the Infection Control Team and members of the clinical team that are available. These will be colour coded (red, amber, green) in terms of whether they are preventable. Consultants are free to make further comments and are asked to help make sure that everything is done to prevent further cases. 4. Monthly hand hygiene audits [National target: zero tolerance CEL 5 (29)] These are already undertaken as part of the SPSP. It is expected that these data are reviewed at Clinical Governance meetings or other relevant meetings to ensure that National and zero tolerance targets are met. Remedial action must be taken if required 8. Areas for Scorecard Monthly Monitoring of Wards and Aggregated Groupings ) Ninewells (admission wards not included). medicine/cardiovascular medical (others) 4, 4HDU, 2, 42, CIU 3. surgery 7-2/HDU 4. renal RDU/22 5. ward 2 6. orthopaedics haematology/oncology 32 /34 8. ward 3 Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 7 of 47

13 2) PRI (admission ward not included). ward 2. wards 3&6 3. ward 5 4. wards 7&8 5. Tay, Earn and Stroke wards 6. ITU 7. RDU 3) Stracathro. Ward 2 2. Ward 3 3. Surgical Unit 4. Stroke unit 4) Royal Victoria Hospital. Ward 2. Ward 2 3. Ward 3 4. Ward 4 5. Ward 5 6. Ward 6 7. Ward 7 8. Ward 8 9. Roxburgh East. Roxburgh West 5) CHP. Dundee CHP 2. Angus CHP 3. Perth & Kinross CHP Other areas not on the scorecard will continue to be monitored as part of the routine surveillance/audit and infection control programme and especially action is required in relation to hand hygiene. G Phillips Lead Infection Control Doctor February 29 Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 8 of 47

14 APPENDIX : Scorecard May 29 Hand Hygiene Complianc e Antimicrob ial Prescribin g Medic al 8 (9) No data (8) Surgical 7 (7) Scorecard Results as per Directorate, Ninewells Hospital May 29 No data Awaiting (5) () Orthopae Ward 2 dics 7 (85) 95 (95) No report (No report) Renal 95 (9) No report (No report) Haem/ Onc Ward 3 95 (9) No report (No report) () No data (8) Medical (4,4HDU,2, Target CIU,42) 95 (9) > 95% No data (8) > 95% (Orthopaedics Antibiotic Prophylaxis, All other areas Empirical Prescribing) Sharps Injuries () () () () () () () () HAI S. See separate tables below aureus () () () () () Bacteraem ias Education () (2) 4 (4) 7 (7) 7 (7) 2 (2) 2 (3) () > 4 Environme ntal Cleaning (92) (92) (94) (97) (93) (94) (97) (93) > 9% Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 9 of 47

15 New MRSA Acquisition s New C. Diff Acquisition See separate tables below () () s VAP 5.37 (6.77) SSI CVC Associated Infections PVC Bundle Wd 96 Wd 2 9 Awaiting (Brea st- 6.2) 8.53 () (Vasc ularn o data) Ward 8 No data Awaiting () Ward 9 87 Ward 7-87 () () (3) (.48) () () 7.75 (4.95) WARD 6- Ward 32 - Ward 4-97 Ward 22-9 () 2 () () () 4 HDU < 5/ Ventilator days < 4.9% (Breast) < 9.9% (Vascular) <.5% (Ortho) < / Catheter days (Haem/Onc) < 3/ Catheter days (All other areas) > 95% Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page of 47

16 CVC Maintenanc e Bundle CVC Insertion Bundle Wd 3- Ward Wd8 No 8 data Ward Ward Ward 2-9 HDU Ward 34-6 Ward 22- Wd 32 RDU - 8 Wd 34 6 CIU - Ward HDU HDU 94 4 HDU NB: Previous Month s Score in Brackets Awaiting, unable to collate data until end of month for May due to 3 day surveillance for SSI Antimicrobial Prescribing, white for Ward 2, Renal and Haem/Onc as no scores from November due to change in prescribing policy Red > 95% > 95% Amber Green Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page of 47

17 Environmental Cleaning scores provisional as not received from Domestic services Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 2 of 47

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26 Ward 4 Scorecard February 29 March 29 April 29 May 29 Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 2 of 47

27 Hand Hygiene Results for Non-Scorecard Wards, Ninewells Hospital May 29 Hand Hygiene Complia nce Ward 23a No data (85) Ward 23b No data (No data) Ward 24 9 (No data) Ward 25 () Ward 26 No data (No data) Ward 27 () Ward 29 9 (95) Ward 3 No data (No data) Ward 35 No data (No data) Ward 36 8 (No data) Ward 37 No data (95) Ward 38 () Ward 4 No data (9) Ward 4 No data (No data) Target for Hand Hygiene Compliance is > 95% Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 22 of 47

28 Hand Hygiene Compliance Antimicrobial Prescribing Scorecard Results as per Directorate, Perth Royal Infirmary May 29 Ward Medical Ward 5 Orthopaedi cs (75) (95) (9) () No data (85) No data (86) No data Awaiting (85) () Care of the Elderly ITU RDU Target 9 (8) No data () () No report (No report) () > 95% NO REPORT (No report) > 95% (Orthopaedics Antibiotic Prophylaxis, All other areas Empirical Prescribing) < % Care of Elderly Sharps Injuries () () () () () () () HAI S. aureus () (2) () () () () () Bacteraemia s Education () 3 (3) 5 (5) () 3 (3) 3 (4) () > 4 Environment al Cleaning (94) (9) (94) (92) (9) (92) () > 9% New MRSA Acquisitions (2) (3) () 4 () 2 (2) () () New C. Diff Acquisitions () (2) () () (4) () () Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 23 of 47

29 VAP < 5/ Ventilator days SSI Awaiting <.5% (3.6) CVC Associated Infections < 3/ Catheter days PVC Bundle NO DATA No data > 95% CVC Insertion > 95% Bundle CVC Maintenance Bundle 7 6 > 95% NB: Previous Month s Score in Brackets Awaiting, unable to collate data until end of month for May due to 3 day surveillance for SSI Antimicrobial prescribing, white for ITU as no scores from November due to change in prescribing policy Environmental Cleaning scores provisional as not received from Domestic services Red Amber Green Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 24 of 47

30 Scorecard Results as per Ward, Royal Victoria Hospital May 29 Hand Hygiene Complianc e Antimicrob ial Prescribin g Sharps Injuries HAI S. aureus Bacteraem ias Ward Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 95 (95) No data () () () Education 5 (4) Environme ntal (99) Cleaning Bed Occupanc y NOT AVAILAB LE (95) No data () () () (2) (98) NOT AVAILA BLE () No data () () () 2 (2) (97) NOT AVAILA BLE No data (No data) No data () () () 2 (2) (9) NOT AVAILA BLE 95 () No data () () () 2 (2) (98) NOT AVAILA BLE (94) No data () () 2 () 2 (2) (95) NOT AVAILA BLE 9 (85) No data () () () 6 (6) (93) NOT AVAILA BLE 85 (85) No data () () () () (93) NOT AVAILA BLE Roxbur ghe East 95 (9) No data () () () 5 (5) (94) NOT AVAIL ABLE Roxbur ghe Target West 95 (9) > 95% No data () () () 5 (5) (97) NOT AVAIL ABLE > 95% > 4 > 9% < 85% Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 25 of 47

31 New MRSA Acquisition s New C. Diff Acquisition () () () () () (2) () 2 () () (2) () () () () () () () () () () s VAP < 5/ Ventilator days SSI <.5% PVC Bundle CVC Insertion Bundle CVC Maintenan ce Bundle No data No data > 95% > 95% > 95% NB: Previous Month s Score in Brackets Environmental Cleaning scores provisional as not received from Domestic services Red Amber Green Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 26 of 47

32 Scorecard Results as per Ward, Stracathro Hospital May 29 Hand Hygiene Compliance Ward 2 Ward 3 Surgical Unit Stroke Unit Target No data 95 9 () () (95) (9) > 95% Antimicrobial Prescribing No data (8) No data (8) No report (No report) No data (8) > 95% Sharps () () () () Injuries HAI S. aureus () () () () Bacteraemia s Education () () 5 (4) () % Environment al Cleaning () () () () > 9% New MRSA Acquisitions (2) () () () New C. Diff Acquisitions () () () () Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 27 of 47

33 VAP < 5/ Ventilator days SSI <.5% CVC Associated Infections < 3/ Catheter days NB: Previous Month s Score in Brackets Environmental Cleaning scores provisional as not received from Domestic services Antimicrobial prescribing, white for Surgical Unit as no scores from November due to change in prescribing policy Red Amber Green Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 28 of 47

34 Scorecard Results for Dundee, Angus and Perth & Kinross CHP May 29 Angus Perth & Kinross Hand Hygiene Compliance 96 (98) Antimicrobial Prescribing NO DATA () Needlestick Injuries () HAI S. aureus Bacteraemias () Cleanliness Champions 3 (3) Alert Conditions () New MRSA Acquisitions () New C. Diff Acquisitions () Environmental Audits Fed > 95 Back (> 95) 9 (75) NO DATA (24) () () < 2 (< 2) () () () > 95 (> 95) NB: Previous Month s Score in Brackets Red Amber Green Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 29 of 47

35 Hand Hygiene Antimicrob ial Prescribin g Sharps Injuries HAI S. aureus Bacteraem ias Ward Data Colle ction Not Starte d () () Dundee CHP Scorecard May 29 Carseview Ashludie Royal Dundee Liff Ward Ward Ward Ward Ward Ward Ward Ward Ward Ward 2 LDAU IPCU Data Data Colle Colle ction () () ction () Data Collection Not Started Not Not Starte Starte d d Data Collection Not Started () () () () () () () () () () Education Environme ntal Data Collection Not Started Cleaning () () () () () () () () () () () () () () Ward 5 () () Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 3 of 47

36 New MRSA Acquisition s New C. Diff Acquisition s () () () () () () () () () () () () () () () () () () () () () () () () () () () () NB: Previous Month s Score in Brackets Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 3 of 47

37 Targets for Angus and Perth & Kinross CHP Scorecards. Hand Hygiene Compliance Audit of 2 staff as per Audit Tool. RED 94% GREEN 95% 2. Antimicrobial Prescribing. Compliance with empiric antibiotic policy: based on restricted antibiotic usage as a % of total usage Perth & Kinross and Dundee Angus Restricted v Total Compliance with Empiric Policy (ARI) RED 5% RED 49% AMBER 5% AMBER 5-94% GREEN % GREEN 95% 3. Needlestick Injuries identified via the AIM System RED 2 AMBER GREEN 4. HAI Bacteraemia RED 2 AMBER 2 GREEN 5. Education. Number of Cleanliness Champions on the Ward per month RED 2 AMBER 3 GREEN 4 6. Alert Condition Organisms that are reported within 24 hours to ICT/ the total amount identified RED 5% AMBER 99%-5% GREEN % 7. New Acquisitions of MRSA in hospitals RED 3 AMBER 2 3 GREEN 8. New Acquisitions of C.Difficile in hospitals RED 3 AMBER 2 3 Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 32 of 47

38 GREEN 9. Environmental Audit Feedback. The number of audits fed back within the agreed timescale RED 5% AMBER 5%-94% GREEN 95% Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 33 of 47

39 APPENDIX 2: SGHD HAI Action Plan RAG Report (June Response) NHS BOARDS NHS Tayside Response Action: 2. All Boards will empower their Charge Nurses to deliver against their responsibilities Lead: NHS Boards: Chief Executives Completion Date: October 28 Status: COMPLETE Progress: In NHS Tayside the majority of our SCNs are Cleanliness Champions and there is a rolling programme to ensure that all SCNs complete the programme. NHS Tayside is implementing the job description recommended by Leading Better Care. All SCNs currently participate in environmental audits. Local Completion Date: December 2 Comments/Outstanding Actions: Following review of environmental audit procedures a short life working group is being established to develop NHS Tayside standing operating procedures identifying roles and responsibilities of all staff Action: 2.2 Implement the recommendations in the Senior Charge Nurse Review Lead: NHS Boards: Chief Executives Completion Date: December 2 Status: GREEN Progress: Both the Executive Team and Delivery Unit Committee support the full implementation of the revised SCN role. A programme board has been established with three supporting workstreams. An enabling organisation, role development and Quality and Patient Experience Learning Communities have been established to support all SCNs to develop the knowledge and skills required for the role. Learning Communities commenced November 29. Local Completion Date: December 2 Comments/Outstanding Actions: Action: 3. HAI SCRIBE (Healthcare Associated Infection System for Controlling Risk in the Built Environment) sections 3 &4 to be applied to all existing buildings to ensure fabric of healthcare facilities maintained to minimise risk of infection Lead: NHS Boards: Chief Executives Completion Date: August 28 Status: COMPLETE Progress: HAI SCRIBE implemented in all refurbishment and maintenance projects in across NHS Tayside All NHST premises have been assessed for compliance with HAI SCRIBE. Local Completion Date: January 29 Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 34 of 47

40 Infection Control training has been given to Estates staff this will be revised to include use of HAI SCRIBE. Local Completion Date: November 28. Revised to December 28. Comments/Outstanding Actions: Training on the application of HAI SCRIBE required for Infection Control Nurses to support roll out of Estates training Completed Local Completion Date: December 28 A review of all community premises including application of HAI SCRIBE to existing premises will be completed by January 29 - this is complete. Executive walkabouts to examine and address environmental issues have commenced. Ongoing programme of visits complete Local Completion Date: February 29. Awareness raising and training planned for Capital Projects staff. This training has been carried out Action: 3.3 Planned preventative maintenance programmes reflect requirements of prevention and control of infection Lead: NHS Boards: Chief Executives Completion Date: October 28 Status: COMPLETE Progress: Infection control is considered in all maintenance projects. System now in place to assess level of infection control input. Local Completion Date: November 28 Comments/Outstanding Actions: Action: 4. NHS Boards to have zero tolerance to noncompliance with hand hygiene Lead: NHS Boards: Chief Executives Completion Date: January 29 Status: AMBER Progress: Hand hygiene audits undertaken in all clinical areas and are monitored by Infection Control. High risk areas are monitored using a Balanced Scorecard which highlights non-compliance as amber or red depending on result Hand hygiene policy reviewed and updated September 28. All staff have access to this policy. Local Completion Date: March 29. The bi-monthly reports being sent to the Board. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 35 of 47

41 Comments/Outstanding Actions: Hand hygiene compliance and its importance to NHST to be included in all recruitment packs. Multidisciplinary group will look at implementation of this and dress code in March. Complete Zero Tolerance approach incorporated in to Hand Hygiene policy. This policy implemented in May 29 awaiting ratification of Dress Code Policy. Action: 4.3 NHS Boards to report hand hygiene compliance (staff and visitors) and facilities on a hospital basis to 2 monthly Board meetings Lead: NHS Boards: Chief Executives Completion Date: January 29 Status: COMPLETE Progress: 2 monthly reporting put in place immediately. Reports going to HAI Network bi-monthly (which is chaired by the CEO and feeds in to the Board), Executive Management Team, Tayside Improvement Panel and the Improvement and Quality Committee. Comments/Outstanding Actions: Public Partnership Group HAI members carrying out observations of visitors at selected ward entrances. These are planned for the whole of 29. The results from these observations will be reported locally and to the Board. Action: 5. NHS Boards to ensure HAI budget requirements are reflected in capital, maintenance and operational programmes Lead: NHS Boards: Chief Executives Completion Date: April 29 Status: AMBER Progress: Finance detail code in place for all infection control projects and maintenance programmes. This will give a benchmark for budgets in 29/. Comments/Outstanding Actions: Finance code has been in place 28/9 awaiting confirmation of 29/ budgets. Action: 5.2 NHS Boards to have identified budget for urgent repairs and replacement equipment available to Charge Nurses Lead: NHS Boards: Chief Executives Completion Date: January 29 Status: Red Progress: Current repairs are resourced through existing revenue budgets. Capital funding is available via a medical equipment group for prioritised equipment. HAI implementation fund supports environmental audit results, and compliance with timescales is monitored and audited through the Executive Team. Review of change demonstrated improvements can be made with Senior Charge Nurses holding budget for repairs. To be rolled out across NHS Tayside with Senior Charge Nurse review. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 36 of 47

42 Comments/Outstanding Actions: To be actioned/discussed with General Manager once Management re-organisation completed September 29. Action: 6. All patients to receive information on HAI Lead: NHS Boards: Chief Executives Completion Date: November 28 Status: COMPLETE Progress: An HAI leaflet developed with the PPG is available to all patients across NHST. Comments/Outstanding Actions: Action: 6.3 All information is available in a variety of formats that facilitates public understanding Lead: NHS Boards: Chief Executives Completion Date: November 28 Status: COMPLETE Progress: Leaflets are available in plain English although we offer to provide translated versions on request. Hand hygiene visual messages at entrances to Ninewells and PRI providing information in several languages. HAI leaflets translated into top 5 languages within Tayside. Comments/Outstanding Actions: This will be evaluated as part of the PPG HAI Forum Work Plan Action: 7. NHS Boards to implements requirements of CEL 3(28): Prudent Antimicrobial Prescribing: The Scottish Action Plan For Managing Antibiotic Resistance And Reducing Antibiotic Related Clostridium difficile Associated Disease. Lead: NHS Boards: Chief Executives Completion Date: August 28 Status: COMPLETE Progress: All recommendations from CEL 3 (28) are being fully implemented as below; NHS Tayside has had an Antimicrobial Management Group (AMG) set up for many years. It links with ADTC, HAI Network, ICM, Primary care CHPs as required. Regular reports on consumption of antibiotics are set up for key areas AMG reviews all SMC advice for antimicrobials before local implementation AMG monitors local resistance patterns and do not routinely report restricted agents on reports All GP practices have their seasonal variation of quinolones monitored 6 monthly as per HEAT target Restricted anti-microbial policy implemented in Secondary Care. Monitoring of compliance set up for medical, surgical and care of Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 37 of 47

43 the elderly units throughout NHS Tayside. Restricted policies for Community hospitals in place. Restricted GP prescribing policy complete Updated protocol for treatment of C difficile patients available to primary and secondary care staff Additional antimicrobial pharmacist started May 9 Review of major surgical speciality prophylaxis regimes complete in accordance with SIGN and SAPG guidance. Education of independent sector pharmacists and nursing homes arranged for June 9 Comments/Outstanding Actions: Local Completion Date: Action: 8. Scottish Patient Safety Programme (HAI elements) are integrated with HAI agenda at NHS Board level Lead: NHS Boards/Scottish Patient Safety Programme Completion Date: January 29 Status: COMPLETE Progress: Working jointly on development and roll out of CVC, VAP and CAUTI bundles. Hand hygiene audits fully integrated. Complete. Comments/Outstanding Actions: Implementation plan for PVC and CVC bundle in progress. Compliance to be reported to performance management group, Clinical Governance etc. Action: 8.2 Progress on implementation of Scottish Patient Safety Programme (HAI elements) to be included in HAI reports to 2 monthly Board Safety Patient care bundles associated with HAI Lead: NHS Boards Completion Date: January 29 Status: COMPLETE Progress: hand hygiene included in Balanced Scorecard in high impact areas and reported to HAI Network bi-monthly, Executive Management Team, Tayside Improvement Panel and the Improvement and Quality Committee. Comments/Outstanding Actions: Action: 9.3. NHS Board s infection control policies include primary and community care Lead: NHS Boards: Chief Executives Completion Date: December 28 Status: COMPLETE Progress: All local Infection Control policies apply to primary and community care. Complete. Comments/Outstanding Actions: Several policy sections under review. Local completion date December 28. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 38 of 47

44 Action:. Structure and resources to provide effective infection control service across NHS Board area (hospital and community) assessed and agreed by NHS Boards, including: Human resources Equipment Budget Lead: NHS Boards Completion Date: October 28 Status: AMBER Progress: This has been an on-going process in Tayside. The Infection Control team was reviewed and redesigned in 26/7 and is currently being looked at again. New money has been made available to support the Infection Control team. NHS Tayside is actively considering the considering the creation of a Directorate of Infection Prevention and Control. The final structure is yet to be agreed however the current structure remains in place with the Nurse Consultant (HAI) post in the process of being recruited to, and the Infection Control Manager Post being covered on a temporary basis by the Assistant Director of Nursing. Comments/Outstanding Actions: Initial draft of proposed restructure is currently out for consultation with key individuals. Infection control Manager s post interviews to be held end of June 29. Action:.2 NHS Boards policy/guidance on completing death certificates reviewed to include documenting death associated with HAI Lead: NHS Boards Completion Date: December 28 Status: AMBER Progress: Awaiting guidance from either HPS or the SGHD to be in line with all areas in Scotland. New guidance has been issued from the Procurator Fiscal s office and we have contacted them to seek clarification on some issues. Otherwise no specific instructions have been issued to staff over and above what is already required of them in death certification as regard causes with or without HAI. We would find it helpful is this was addressed at national level. A flow chart has been produced to help staff and is with Medical Director for review prior to discussion with the Procurator Fiscal and other Clinical staff. This is now with CLO and SGHD for comment. Local completion date: End of April 29 Comments/Outstanding Actions: Informed by HAI Task Force that issue is currently with CMO. Further implementation therefore on hold. Flow chart has been assessed by Legal Office Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 39 of 47

45 Action: 2.2 NHS Boards local surveillance to include setting of control limits and trajectories for reduction of rates / incidence of HAI Lead: NHS Boards Completion Date: December 28 Status: COMPLETE Progress: Complete. Comments/Outstanding Actions: Action: 3. NHS Boards Risk Register details HAI risks Lead: NHS Boards: Chief Executives Completion Date: September 28 Status: COMPLETE Progress: HAI risks regularly reviewed and updated via SMART system. Comments/Outstanding Actions: The link between the corporate and operational risks is under review. Environmental audit results are kept on a risk register which is shared with the EMT on a monthly basis. Local Completion Date: End of October 28. Action: 3.2 HAI incidents and issues recorded on NHS Boards Risk Register reporting systems and reported to 2 monthly Board meetings Lead: NHS Boards: Chief Executives Completion Date: January 29 Status: COMPLETE Progress: System in place to review all HAI recorded incidents and will be reported into Health and Safety Management Group and HAI Network from December 28. Comments/Outstanding Actions: Action: 5. NHS Boards to self assess current compliance with QIS HAI Standards (March 28) Lead: NHS Boards: Chief Executives Completion Date: December 28 Status: COMPLETE Progress: Any outstanding issues have been included in the Infection Control Annual Work Programme from which an exception report is submitted to the HAI Network. Complete. Comments/Outstanding Actions: This is now being reviewed again to inform the 29/ programme of work. Action: 6. All healthcare workers receive appropriate level of HAI education and training in line with position, including antimicrobial prescribing and resistance Lead: NHS Boards: Chief Executives Completion Date: April 29 Status: AMBER Progress: Included at all inductions-content being revised. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 4 of 47

46 Local Completion Date: December 28. Local education strategy developed and will be implemented from November. This includes a training matrix which details all available and levels of training for each staff group. Local managers will then agree training as part of the PDP process. Local Completion Date: November 28. Complete with exception of antimicrobial prescribing - to be included in training by end of May 29. Comments/Outstanding Actions: Education strategy developed and implemented, this now requires evaluation/impact assessment. Action: 6.2 Infection Control staff undertake appropriate level of education and training Lead: NHS Boards: Chief Executives Completion Date: April 29 Status: COMPLETE Progress: All infection control staff have personal development plans which are guided by corporate HAI objectives. Complete. Comments/Outstanding Actions: Action: 9.2 Cleaning matrix and schedule including discipline responsible for cleaning is available in all healthcare settings Lead: NHS Boards: Chief Executives Completion Date: September 28 Status: AMBER Progress: Domestic Services staff currently comply with national cleaning standards. The Lothian cleaning matrix has been adapted for local use and is currently being consulted on. Roll out is planned during November. Local Completion Date: November 28. This matrix is complete and implemented across NHS Tayside. Comments/Outstanding Actions: Cleaning matrix implemented but requires evaluation/review completed, being mapped against new cleaning standards prior to launch. Action: 2. All staff to have HAI objective in annual professional development plans Lead: NHS Boards: Chief Executives Completion Date: April 29 Status: AMBER Progress: All nursing staff have HAI objectives. Comments/Outstanding Actions: this is being promoted and discussed at the launch of the HAI Education Strategy. Advice circulated to all managers. PDPs completed. A sample of PDPs require review to ensure compliance. To be completed august 29. Infection Prevention and Control Scorecard Strategy 9- FINAL[2].doc Page 4 of 47

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