Northern Health and Social Care Trust

Transcription

1 Ref: TB28/58/12 Appendix D Northern Health Social Care Trust Subject: overnance Content: Board Assurance Framework Trust Board is responsible for ensuring it has effective systems in place for governance, essential for the of its organisational objectives. The purpose design of the Board s Assurance Framework is to ensure that the Board can be effective in driving the delivery of its objectives. This document assists the Board in identifying, managing minimising the principal risks to achieving the corporate objectives shows the position at March. IPC Corporate Delivery Plan to consider progress at March on the Infection Prevention Control Corporate Delivery Plan 2010/2013. Author: Dr P Flanagan FOR CONSIDERATION Date: 16 March 1

2 IPC CORPORATE DELIVERY PLAN PRORESS AT MARCH Incorporating recommendations from Dr Patel s visit July 11 All sub-objectives to be delivered by December 2011 sustained thereafter with regular monitoring/testing for assurance. Definitions RA Rating reen on target to deliver actions to PCOPS = Primary Care & Older Peoples Services achieve objective N.D.L. Nominated Directorate Lead for IPC Amber of actions AHS = Acute Hospital Setting not certain/doubtful. MHD = Mental Health Disability Directorate Red not likely to deliver objective in Childrens = Children s services Directorate timeframe. CCD = Corporate Communications Department IPC = Infection prevention control PPMSS = Planning, Performance Management, Support Services CORPORATE INFECTION PREVENTION AND CONTROL DELIVERY PLAN 2

3 Objective 1: To deliver high quality, evidence based treatment care 1.1 Re-survey 20 staff to ensure All staff will have access that they can use intranet to the Regional IPC find the manual, take local manual in relation to action as appropriate. prevention of Healthcare Report survey findings to Associated Infections. Directorate IPC group or IPCEH committee. AHS, PCOPS & Children s staff in Trust facilities all have access to the regional ward manual through Staffnet. Easy link from front page of staffnet Rom surveys of staff provided assurance of knowledge of how to access policy. Homecare staff T/R staff have hard copy access. Access to intranet included in facility induction. Introduce annual review of IPC policy (as appropriate) with each policy reviewed, provide 1 page summary of content. NDLS IPC Team Timeframe RA Evidence of 30 th Sept 2011 Completed From Sept 11 A Survey results. Departmental induction content. Homepage of Staffnet has IPC feature that takes staff straight to regional manual link. View IPC policy 1.2 Rolling Audit Programme in place to measure compliance with best practice to prevent HCAI to include: - H Hygiene - Environmental Cleanliness - Commodes - Mattresses - IPC Nurse Audits - High Impact Interventions (HIIs) (This list is not exhaustive). Hospitals Facilities comply with requisite audit programme. Performance is reported above 95% in almost areas. Peer audit now embedded in practice Relevant HII SPI Care Bundles in use in all acute facilities. Essential steps programme being rolled out in community audit findings reported on dashboard to IPCEH overnance Meetings. Rolled out in NNU acute paeds All audit findings to be collated presented at Directorate IPC group. iven the consistent compliance findings of HII audits the time involved in producing data, senior leaders will determine if these audits add value if the time involved is justified. NDLS DIPC /DON/ Head of ov August 2011 Complete roll out April 12 Reduced variance between ward audit findings IPCN audit findings. Minutes of Directorate IPC Meeting. Audit Reports 3

4 1.2 contd. Regional audit tool now in use across the Trust Timeframe RA Evidence of Audit Reports 1.3 Develop framework implement competency assessment for peripheral line insertion, ongoing care removal. IPCN audit plan includes 6/12 monthly H Hygiene MRSA & C Diff validation audits. Line champion appointed, Feb 12. Project plan under development. Nurse training in ANTT completed. Medical training delivered doctors. Complete project plan Implementation project plan..line champion DON/ DIPC March 31 st To be confirmed Training plan reports. Better RCA data for bacteraemia. Reduction in the number of Bacteraemias 1.4 Infection Prevention Control Link Workers will encourage promote a culture of best practice within the clinical area. sustained. All clinical facilities have IPC Link Nurses, some community areas also have link support workers. Link Nurses have all completed a module in IPC. Poor attendance of IPC Link Nurses at meetings with IPCN team due to ward pressures. Link nurse study day delivered in December.DON relaunched role. IPCT continue to work with support link nurses. Lead IPC nurse with NDLs May 2011 ongoing Reports on attendance minutes. 1.5 IPC Nurses will work with Acute Hospitals Practice to continue. IPC lead nurse Minutes of directorate 4

5 clinical staff providing advice guidance to ensure best practice in relation to HIIs prevention of HCAIs: 1. at directorate meetings 2. during facility visits 3. when providing targeted support. sustained. 1.6 Compliance with matory training requirements in relation to HCAI through delivery of a rolling IPC training programme. - All staff have IPC awareness training at induction. sustained. 1.7 Training Delivery Plan for nurses all other staff groups delivered by IPC nurses, in collaboration with Nurse Education Development Consortium, to comply with regional guidance. sustained. 1.8 Promote encourage Each acute facility has an aligned IPCN. IPCNs attend directorate meetings. If a facility has a poor audit the IPCN provides support until the unit s stards are raised. IPCN attends daily bed management meetings on both acute hospital sites.. Some difficulty with data capture but high level of compliance. IPC training to be included in consultant appraisal from June New IPC training model introduced Dec 11 Regional guidance never issued. Progress on target. Re-establish training subgroup to refresh training plan A number of research projects established in collaboration Practice to continue. Head of Medical Education to advise on evidencing compliance levels with doctors in training. Medical staff seek DHSSPS position on stardised training content. 5 Ward managers Lead IPC nurse I Head of Medical Education Dr Dornan Training Sub roup Chair IPC training subgroup chair Timeframe RA Evidence of meetings. May June R Audit reports Minutes of IPCECH meetings.. Manual training records. Revised training plan. Dec 2011 Revised training plan for Completed Development of IPC R&D Strategy. Further research is Director of Sept 2011 Research papers

6 Research with Trust Pharmacy ongoing with submissions for Development related to QUB a number of publication being made In IPC publications have been addition a Research sustained produced since 2010 This Development Office includes three full papers Fellowship has been attained relating to blood cultures, c.diff with work commencing in outbreak prescribing September 2011 for three linked to ESAC as well as years. three letters regarding MRSA management,h hygiene hospital antimicrobial policies. Objective 2: To provide a clean safe environment for treatment care 2.1 Thoroughly clean Intensive cleaning programme buildings across the in operation across the Trust. NHSCT environment. Domestic Services provide a cleaning service to all NHSCT Facilities. Cleaning stards are monitored by the Domestic Services Management Team in conjunction with ward/department Managers the Infection Control Team. Introduce Annual Environmental Hygiene Report for Trust Board. First one to be submitted to Trust Board by end June. Infection Prevention Control IPC Doctor DON Assistant Director Support Services Assistant Director Support Services Timeframe RA Evidence of Ongoing rolling programme September 2011 Publications Audit reports HCAI Dashboard/Trust Board Performance Report Trust Board Minutes. Patient/Manager satisfaction survey March/April 2011 very positive (Antrim). 2.2 Cleaning in all areas in agreement with agreed cleaning schedules contd Acute & Community Hospitals all areas have cleaning schedules. Cleaning schedule completed in place for Community Equipment store. Home Care workers are compliant with cleaning Monitor cleaning schedules. Cleaning schedules for residential respite units are being completed by Heads of Residential Respite units with uidance Ward Managers Facility managers Domestic Services Managers ongoing September 2011 Domestic Supervisors/Ward Managers at daily monthly Environmental Cleanliness Audits observe if current Work Schedules are in place in domestic 6

7 2.3 Monitoring review of cleanliness of environment on a daily basis schedules for Trust property within clients homes Acute Hospitals daily review by ward sister domestic supervisor. Clutter is a recurrent problem. from Domestic Services Management. To review cleaning schedules for AHP Treatment Rooms. Develop SLA s with facilities. Continue monitoring reviews of environmental cleanliness. Plan de-clutter initiatives quarterly. Next Dump the Junk Event planned for June Assistant Director Corporate Services Ward managers Domestic services supervisor Assistant Director Support Services Timeframe RA Evidence of stores. Domestic Services Managers Domestic Services Supervisors update June 2011 A Work Schedules if any changes are made to organisation of domestic service. All Work Schedules to be dated. Assistant Domestic Services Managers in the Community are currently liaising with Head of Residential Respite Units to complete Work Schedules. This is an ongoing process. ongoing June 2011 A Corridors wards free of clutter. Minutes of IPCEH. 2.3 contd Bed storage a problem (Antrim). Cardiac car garage now being used for bed storage. Observational visits in place Rota options being worked up for the appointment of a bed/mattress co-ordinator for Antrim. JD has been gradedat b 2. Clear Corridor Policy being DON AHS Director June 2011 Observe for clutter on leadership walkrounds. Refurbishment of 7

8 for Community Hospitals / Residential Day Care facilities. Capital funding approved to refurbish bed store in Antrim. Completion due Oct developed. Timeframe RA Evidence of Antrim Bed Store complete. 2.4 Implementation of a rolling audit programme to demonstrate a consistently high stard of environmental cleanliness is delivered. 2.5 Facilities are maintained in accordance with Regulatory Estate requirements. Acute Hospitals in place Cleaning schedules in place for AHP Clinics Peer audit now embedded practice. Audit programme in place for environmental cleanliness within community. A new process has been agreed for prioritisation of minor works, with a patient safety dimension. Response times have been agreed. Evaluate new process with directorate managers. Funding secured to appt. 2 to manage process meet agreed stards Assistant Director Support Services Director of PPMSS. Roll out commence June 2011 October 2011 June R New system documented for inspection. 2.6 Design of new facilities refurbishment of existing estate to reflect IPC guidance. IPC team involved in scrutiny of plans at design stage commissioning of new facilities all refurbishment projects. To continue. Director of PPMSS ongoing. Plans for new facilities. Established 2.7 Early identification of Through the use of the Monitor incident reports Bed management Ongoing CE 8

9 patients with potential infective status isolation in a timely manner. Daily completion review of Isolation Risk Assessment Tool (IRAT) to ensure safe appropriate patient flow. Infection Control Admission Risk Assessment Form (ICARAF)compliance is high. ICARAF is completed on a daily basis reviewed at bed management meetings. Ward staff identify patients who pose a potential IPC risk initiate precautions. IPC team immediately notify wards of suspicious lab results or confirmed infectious organisms so that appropriate action can be taken promptly. High level of lab testing for C Diff. uidance on testing issued December Audit findings suggest poor compliance. Smart stool resources issued July 2011 RCA summaries to identify any failure in this process. Apply learning from Expert review of MSRA bacteraemia cases in respect of isolation suppression therapy Quarterly audit of use of IRAT to be carried out. Process for collation of audit data not reliable in C way.under review. Evaluate use of Smart Stool resource pack taking account of new regional guidance on testing whch will be issued soon. Ward Managers. Line champion /ward managers DON/Deputy DON IPC Lead nurse IPC Doctor Timeframe RA Evidence of seek evidence of best practice through RCA meetings June 12 Established in To continue July/Oct June12 Sept 12 High level of compliance reported to IPCEH. IRAT Forms Reduction in number of C Diff specimens sent for C Diff testing. 2.8 Development of guidance The Trust has guidance on the No further action Director of 2011 IRAT Forms, refer to 9

10 for prioritising of single rooms for isolation of patients for infection control purposes. prioritisation of single rooms for patient isolation. Any further business cases for inpatient facilities will specify single room accommodation en suite facilities. PPMSS Timeframe RA Evidence of onwards Re-designation of Ward A1, Antrim Area Hospital as isolation cohort ward when necessary Appropriate Outbreak Management with roles responsibilities clearly defined. Staff aware of patient experience issues raised at C Diff Inquiry re isolation rooms. A research project regarding Patient Staff Experience of being care for in an isolation facility to be undertaken. Local guidance in place (draft). Policy guidance approved. Need to Audit the frequency of the implementation of the guidance identify learning from same to further inform practice. Practical Steps for Outbreak Management in the clinical environment developed disseminated. Outbreak policy has been revised. Account has been taken of C Diff Inquiry recommendations. Implement in full. DON/Deputy DON Patient Flow Manager/ Assistant Lead IPC Doctor Lead IPCN June Research Report. Established/ completed Ongoing A uidance available for reference. June 2011 Established/ completed Post outbreak reports. Revised Outbreak policy. Completed 2.11 Strong clear Corporate co-ordination of PS Leadership walk rounds now Trust May PS Leadership 10

11 leadership at the highest level demonstrated through Patient Safety (PS) Leadership Walkrounds with a focus on infection prevention control Leadership Walkrounds for Assistant, Senior Management Team Non- Executive focussing both on IPC the patient safety issues. Decision taken to talk to patients re their experience when doing walkrounds. uidance developed Support Services walkabouts in conjunction with the IPC Team ongoing. Nursing staff now attend. include speaking to patients. Reporting mechanism to be developed. overnance Manager (patient safety). Assistant Director Support Services Timeframe RA Evidence of walkrounds reports. November 11 Support Services walkabout reports. Public Representatives from IPC Committee attend when possible Development of action plans to implement recommendations from IPC Nursing Audits external reviews eg. RQIA inspections Action plans developed after every audit, internal external audit findings on IPCEH agenda directorate IPC agenda. Summary progress against action plans are monitored reviewed at IPCEH Committee overnance Management Board (MB). Directorates look for recurrent issues in audits across facilities take managerial action if necessary. Assistant / overnance Leads Corporate Trust overnance Manager ongoing. Ongoing. Audit results action plans available for inspection. Minutes of IPCEHC MB Objective 3: To establish timely effective HCAI surveillance programmes systems to identify trends, investigate clusters adverse incidents to share learning 11

12 3.1 ICT enabled surveillance of organisms to support detection of emerging trends problems 3.2 Provision of timely information re Trust incidence of Clostridium difficile, MRSA MSSA bacteraemias other alert organisms. Dr Scott leading the development of HCAI dashboard Phase 1 live from March 31 st, phase 2, May 12 All new C.Diff MRSA cases are reported daily to DIPC. enerate reports with greater analysis of data post on staffnet for clinical staff to access. Develop dashboard to meet IPC surveillance requirements HCAI system at 3.1 will address all surveillance needs Timeframe RA Evidence of Professor Scott Oct 2011 R Surveillance reports data on staffnet. Lead IPC doctor Ref 3.1 Oct 2011 R Reports on analysis of alert organism. Information on staffnet 3.3 Identified accountability for analysis response to management of emerging patterns / trends. IPC team accountable for analysis of emerging patterns trends in alert organisms. Clinical teams accountable for taking the appropriate action as directed by IPC team management. DIPC responsible to CE Trust Board. Continue to promote ownership of HCAI with clinical teams in all relevant communications. Consider ward based review of HCAI performance after visit to SHSCT. DIPC/DON/ Operational June 2011 Evidence of communication between IPC Team Clinical Teams e.g notes of meetings. Clinical forum meeting with CE. IPC Doctor carried out MRSA bacteraemia case analysis for 211 cases Dr Kearney Dec

13 3.4 Root Cause Analysis (RCA) to be completed by clinical team on all newly reported cases of Clostridium difficile MRSA bacteraemia. RCA process for C Diff has been reviewed RCA findings are reported at directorate IPC meetings IPCEH com. Clinicians lead RCA present to CE,MD DON. Audit of RCA process to be carried out. Outcomes from completed? DIPC/Operational NDL/Lead Nurse Timeframe RA Evidence of Ongoing on quarterly basis. ongoing. Audit findings. Minutes of meeting. Directorate IPC roup IPCEH Nominated Directorate Leads to implement monitor action plans to address emerging trends / issues arising from audits RCAs. RCA process for MRSA bacteraemia is completed. Community Hospitals Residential Homes - RCA process initiated completed in all new cases of C Diff, MRSA & MSSA Bacteraemia. Currently action plans are monitored through the management line. Action learning to be discussed at the Directorate IPC group chaired by NDL. Assistant & overnance Leads Sept Directorate IPC minutes. Action plans are developed if deficits are found. Completed/ established 13

14 3.5 A Senior Management HCAI review panel to hold individual staff members to account for new cases of HCAI. 3.6 A dashboard of key performance indictors developed, implemented monitored: Environmental Cleanliness H Hygiene Commode Audits Mattress Audits IPC Nurse Audits Staff training by professional grouping - Antibiotic Prescribing - User Feedback CE, selected an IPCN meet clinical teams where a bacteraemia or C Diff has occurred in one of their patients. They review RCA findings share learning. Learning reports issued from RCA meetings A corporate dashboard of identified KPI s presented to SMT Trust Board monthly. Discussed at Directorate Team at monthly AD overnance forums. CE to introduce HCAI performance into monthly accountability reviews. Directorate monitoring of KPI dashboard to continue. Ensure corrective action is taken when performance dips. Action learning to be discussed at the Directorate IPC group chaired by NDL monitoring. Review arrangements for ensuring problems are identified acted on. DIPC Chief Executive DON/Operational DIPC Director. Assistant Lead Nurse Assistant Assistant Timeframe RA Evidence of July 2011 Dec 11 ongoing. ongoing. ongoing. Minutes of review panel. Minutes of accountability meetings. Dashboard minutes of meetings. Performance against KPIs displayed in wards. (list illustrative / not exhaustive). Review escalation arrangements for low compliance with any HCAI KPI s, review action taken. Operational / Assistant Sept

15 Sub-Objectives Timeframe RA Evidence of Objective 4: To ensure all staff are aware of their responsibility accountability for the prevention treatment of HCAIs 4.1 Accountability responsibility for prevention of HCAIs embraced at all levels of the organisation - Infection prevention control is everybody s business is reflected as a core organisational value.. Responsibility for IPC prevention of HCAI s is a sting agenda item on directorate meetings Directorate IPC groups; eneral Managers meetings Ward managers meetings. overnance Management Board overnance Committee. Involve NEDS on leadership walkarounds report findings. Increase clinical engagement in HCAI. Fully develop new accountability structure Local medical governance groups established, to become M-D Head of overnance & Patient Safety Strategic IPC Forum Associate Medical DIR /Dir AHS Sept 12 Minutes of Directorate Meetings. Mi HCAI work relaunched at October 11 event. A new accountability structure has been drafted introducing a strategic forum chaired by the CE. Promote use of reporting system. Ward based teams to review HCAI. Performance supported by local overnance Leads. All staff. ongoing. Minutes of Strategic Forum. A clinical forum has met with CE DIPC further meetings as required. Associate Medical Director/ AHS Sept are responsible for HCAI prevention within directorates report through to Trust Board on HCAI key performance indicators. Corporate HCAI dashboard displays individual facilities results from the IPC audits completed. There needs to be validation of self audits, ref to action at 1.2 Remedial action needed to reduce MRSA bacteraemia. Continued analysis review of individual directorate dashboards at directorate IPC group, IPCEHC MB. Introduce peer audit. 15 NDL DIPC/DON HCAI targets met.

16 4.3 Any breaches of IPC policies are acted on by management. 4.4 review put in place arrangements to ensure effective multidisciplinary approaches to prevention of HCAI. 4.5 Nominated Directorate Leads report on dashboard of KPI s at Directorate overnance meetings Infection Prevention Control Environmental Hygiene Committee. Any breaches of IPC policy to be addressed within line management structures. System developed for colleagues to whistle-blow on persistent breachers. Any recent breaches of policy reports to non Trust staff. All operational directors have implemented the following: -IPC Sting agenda item on all directorate team meetings -NDL role -Training plans for all staff groups -Development monitoring of action plans resulting from IPC nurse audits unannounced inspections by external agencies. IPC Sting agenda item on all directorate team meetings. NDL reports on RCA findings at IPCEH. All breaches to be discussed at Directorate IPC roup. To be reviewed Action learning to be discussed at the Directorate IPC group chaired by NDL. Incident reports to be reviewed quarterly by Directorate IPC IPCEH. When local governance groups become multidisciplinary they will strengthen local approaches Continue with current practice refine reports. NDL NDL/DIPC Operational NDL/Surveillance Officer. Timeframe RA Evidence of A Minutes of Directorate meeting. ongoing. Record of breaches in place monitored. Sept Minutes of meetings. ongoing Minutes papers from meetings. Established 16

17 4.6 Ongoing development of Board to Ward culture to reduce HCAI to the irreducible minimum through: - Implementation monitoring of HCAI action plans - Ongoing training development to enable staff to deliver on the trust s HCAI agenda. Training plans for all staff groups. Action plans are developed to address findings of all IPC audits inspections. Audits are usually performed annually it is now agreed that manager will re-audit areas of poor compliance in the interim to ensure improvement is sustained. IPC nurse audits RQIA reports to be addressed at the directorate IPC group Implement agreed plans for following up on audit action plans sustained progress. System to re-audit monitor improvement being developed bt directorate management NDL AHS management/nd L Timeframe RA Evidence of May 2011 ongoing R Local teams managers demonstrate ownership through practice, policy compliance concern for performance. Trust Board provides visible leadership TB agenda includes HCAI. Established 4.7 All staff have a clear understing of their responsibility for prevention of HCAI as referenced in their job descriptions, objectives, competency assessment job plans. All staff have prevention of HCAI referenced in their job descriptions. uidance issued to medical staff regarding IPC training as part of their PDP. HCAI prevention message to be reinforced annually through review of practice setting of individual objectives. Consultant staff should discuss HCAI as part of appraisal. Management teams Medical Director Ongoing. June 2011 Record of staff objectives. Record of medical appraisals. 17

18 4.8 IPC nurses maintain visibility at clinical level to support staff to prevent HCAI. 4.9 HCAI Performance data: Staff have access to timely reports on Trust incidence of HCAI s local audit results feedback on their performance. Each IPC nurse has responsibility for specific facilities, to support guide staff in the delivery of safe, effective evidence informed practice. IPCNs have almost daily presence on wards (acute). HCAI performance data disseminated through the line management structures to all staff sting agenda item at staff meetings. HCAI performance data displayed on White Boards at the entrance to all facilities. Develop use of staffnet. Lead Nurses now have access to IPC L drive. 18 No further action. Lead IPCN. ongoing. Refer to: Dashboard development at 3.1 Dr Scott DIPC/PPMSS Director Objective 5: To ensure the public have confidence in the care setting the quality of care treatment provided 5.1 Implementation of the HCAI Communication Strategy to provide information to identified target audiences. HCAI Communication Strategy developed regular targeted messages provided. C Diff Inquiry highlighted communication issues. Quarterly news sheet is distributed to Home care workers detailing infection control issues. regular validation audits for C diff MRSA (by IPCN) introduced HCAI communication strategy continues to be implemented within directorates through the directorate IPC groups. Action plan arising from Public Inquiry Recommendations. Assistant Associate Medical Director & Clinical Leads Lead IPC Nurse Timeframe RA Evidence of Ask Ward Managers on Leadership Walkarounds. Sept 2011 R Dashboard data. March 2011 All short term actions by Sept 2011 July 11 Communications Strategy available. C Diff Plan progress reports. Audit Reports Established

19 5.2 Review user feedback processes to ensure the views of service users are informing infection control processes are integrated into the planning, implementation monitoring of same. 2 public representatives on IPECH Committee. Talking to patients re experience being introduced to leadership walkaround. Roll out of improving patient client experience stards. Ongoing To be fully developed reporting mechanisms created. Scrutinise patient experience feedback for IPC issues feedback to wards. Head of overnance & Patient Safety DON Timeframe RA Evidence of Sept 2011 Dec 2011 ongoing. Report from walkarounds. Patient survey results to Trust Board/User Feedback Committee. 5.3 Develop a range of information leaflets on all alert organisms for patients, their families carers, to include: Isolation precautions H hygiene Implications for visiting Treatment Laundry instructions. Information leaflets on most common organisms available from PHA under review. Available on all wards. Staff tick sign date when information given to patients/relatives on IPCN advice sheet. Audit in February 2011 found good compliance. PHA provides all IPC information leaflets. Supplies have been delivered Lead IPCN Deputy DON Head of Communications June onwards. June 2011 for priority leaflets. Leaflets available on request. 19

20 5.4 Clear communication with patients, their families carers to update re: increased incidence / trend within a particular unit / facility. 5.5 HCAI Audit data on display publicly prominently at the entrance to each clinical area / facility. Patients families are not routinely told about the level of HCAI in a ward or hospital. WRiT introduced Dec 11. Document requires doctors to record significant conversations with pt or family outbreak policy will have a linked communications plan for all stakeholders Displayed in all acute facilities on white boards. Audit of use of WRiT planned Objective 6: To ensure safe appropriate prescription of antibiotics 6.1 Compliance with Regional uidelines for Empirical Antibiotic Therapy in Hospitalised Adults. Medicine, Surgery ynae are audited weekly on Adherence to Regional Empirical Antibiotic Policy. Compliance is consistent at 90% above. This is displayed on ward whiteboards. A programme of pharmacy visits antibiotic audits in community hospitals, started April. Anti-microbial ward round established in ICU, piloted in SSW, plan is for weekly rounds in admission wards, Antrim. Continue current practice Consider introducing MRSA, C Diff, commodes, mattress audit to whiteboards. Continue audit programme. Challenge inappropriate noncompliance.. Report findings from antimicrobial ward rounds to consultant Medical Director.. Dr Dornan/ Medical director Ward Managers June 2011 Prof Scott Lead IPC Doctor Pharmacy Timeframe RA Evidence of June12 Audit Findings ongoing May 2011 Oct 2011 Can be seen on each ward. Established Audit results are disseminated monthly a quarterly report is produced by the Antimicrobial Management Team. Reports from antimicrobial ward rounds. Observe whiteboards Results are fed to consultants monthly. 20

21 6.1a Comparative assessment of antimicrobial usage regionally Adherence to the Belfast Trust guidelines for antimicrobial use in children has been audited. The Trust participates via the antimicrobial pharmacist network in monitoring of antimicrobial use. Trust has led regional audit of antimicrobial use in respiratory infection is also leading participating in the regional audit of antimicrobial therapy in UTI Results are being processed. Prof Scott July 2011 Timeframe RA Evidence of Quarterly usage data is reported for each Trust allowing appropriate comparisons to be made. 6.2 Audit programme of antimicrobial compliance in line with policy stards to provide assurance that risks of patients being exposed to high risk antibiotics are being minimised. The use of High Risk antibiotics are restricted throughout the Trust. An exemption form is required by pharmacy prior to dispensing these antibiotics. Ongoing audit of the exemption forms demonstrate average compliance of 95%. Antibiotic policy amended August 2010 to restrict coamoxiclav for CAP. 4 th quarter figures show positive impact. Consultants get monthly feedback on the appropriateness of antibiotics prescribed. Continue current practice High risk antibiotics usage to be reviewed at Directorate IPC group IPCEH. Regular surgical prophylaxis audits currently carried out in Antrim. Prof Scott DIPC, lead IPC doctor Dr Dornan AHS Director Professor Scott ongoing Audit Results are disseminated monthly a quarterly report is produced by the antimicrobial management team. 21

22 6.3 Surgical prophylaxis in line with Trust guidance. 6.4 Appropriateness of antibiotic usage reviewed at Infection Prevention Control Environmental Committee. 6.5 AMT provides strong leadership for prescribing practice. An audit of Surgical Prophylaxis in Antrim Causeway Hospitals was carried out. Regarding antibiotic choice compliance was found to be 80% Review of antibiotic appropriateness usage sting agenda item at IPCEHC. Antibiotic appropriateness audits are reviewed. AMT meets quarterly identifies areas of poor prescribing considers methods of improvement month plan to be finalised at October meeting. Assess findings for learning action points disseminate. Discuss at Directorate IPC group with surgical staff. Also review at IPC directorate roup month plan completed. Under continuous review. Prof Scott Ms etty DIPC Dr Dornan AHS Director Dr Kearney Professor Scott Timeframe RA Evidence of May 2011 June 2011 ongoing A A Audit report minutes of meetings. Audit results minutes of IPCEH. Prescribing data guidance adherence. 22