NHS Highland Infection Prevention & Control Annual Work Plan End of Year

Transcription

1 NHS Highland Board 5 April Item 5.7 NHS Highland & Control Annual Work Plan End of Year Update for COIC Prepared by Catherine Stokoe and Jonty Mills (as of 01/03/) Objective Activity Time Scale Lead Officer Progress RAG 1.1 HEAT TARGETS To achieve the HEAT target of 24 cases per 100,000 acute occupied bed days or lower of Staph. Aureus bacteraemias (SABs) by end of. Approx 60 cases By monitoring each case of Staph. Aureus bacteraemia (SAB) in order to learn from experience and give an understanding of what preventative measures are required. Control & Scottish Patient Safety Programme As of 1 st = 61 SABS (2 MRSA 59 MSSA) (9 preventable and 37 unavoidable; 14 unknown (multiple source); 0 under investigation). Due to the HEAT target trajectory position this is rag rated Red. The root cause analysis process for reviewing learning from device related cases is led by a Board Executive. Learning points are shared at Control Improvement Group and via local team meetings. Focus continues on the reduction of potentially preventable cases, such as those which are device related (2 Peripherally Inserted Central Catheters ; 1 Central Venous Catheter ; 1 Jejunostomy line) The completion of National E (electronic)sab database continues, and work is now underway with Health Protection Scotland to enter further pilot data. RED By ensuring 95% compliance with Peripheral Vascular Catheter and Central 95% reliability with Peripheral Vascular Catheter and Central Venous Catheter has been achieved in some

2 Venous Catheter device bundles in Raigmore and the Rural General hospitals Implement Peripherally Inserted Central Catheter maintenance bundle in Raigmore and the Rural General hospitals by Scottish Patient Safety Programme & Healthcare Associated Quality Improveme nt Facilitator by Scottish Patient Safety Programme & Healthcare Associated areas; however variation is seen in others. This action is therefore rag rated amber. Compliance is monitored through Scottish Patient Safety Programme senior leadership meeting, and there are a number of actions in place to monitor and improve compliance. Additionally the local walk rounds based on the revised healthcare associated infection standards monitoring tool also monitor bundle documentation A re-launch care bundles by Scottish Patient Safety Programme team was held at the end of January to raise the profile of the importance of these. Formal spread to the community hospitals occurred on February 10 th. Due to lack of capacity in the core SPSP team a repeat prevalence audit of vascular devices in use in patients across NHS Highland has not yet occurred. A retrospective review of pathway compliance is currently being undertaken ICM. This action will continue in /2017. The revised target date for this is Sept. Achieved. Peripherally Inserted Central Catheter maintenance bundle is now incorporated into the previous Central Venous Catheter bundle and implemented in Caithness, Belford, Raigmore and Lorn & Islands. Continues to be monitored via Scottish Patient Safety Programme team dashboard. 2015/ Annual work plan 2

3 1.1.4 Devise and implement catheter associated urinary tract infection (CAUTI) bundle in Raigmore and the Rural General hospitals Where applicable, roll out the use of maintenance bundles to all other healthcare settings. Quality Improveme nt Facilitator by Scottish Patient Safety Programme & Healthcare Associated Quality Improveme nt Facilitator Achieved. Catheter associated urinary tract infection bundle has been developed and implemented in Raigmore, Caithness, Belford & Lorn & Islands. Informal implementation within community settings is underway, with formal spread to community hospitals February 10 th, and the inclusion occurring on of District Nursing teams too. 1.2HEAT TARGETS To reduce the number of Clostridium difficile cases to achieve the HEAT Target of 32 cases per 100,000 total occupied bed days in patients age 15 years and over by. Approx 78 cases By monitoring the adherence to the As of 1 st of 16, currently 82 Clostridium RED Clostridium difficile policy to highlight areas for improvement Supported by the & Control difficile infection cases. (4cases of re-occurrence). HEAT target is breached and this is rag rated red. The Lead Doctor met with Board members in December to discuss the CDI position and future interventions. A meeting occurred in February with HPS to discuss Board position, and current and future planned actions. A revised Clostridium difficile infection action plan is in place and monitored through Control of 2015/ Annual work plan 3

4 1.2.2 Recruitment of a data analyst to deliver robust infection control & prevention information thus ensuring that IPC data is analysed thoroughly to inform future practice Explore use of Fidaxomicin (antibiotic) to enhance care treatment of Clostridium difficile toxin patients Continue to monitor hand hygiene compliance in clinical areas Dec 2015 Nov ICM / HPS Lead IPC Doctor Committee. All severe Clostridium difficile infection cases undergo a root cause analysis case review in order to identify learning and improve practice this is led by an Executive Board member. Achieved: Recruitment of a 1 year fixed term data analyst to the team has occurred. Achieved: Fidaxomicin has been used for patients suffering recurrent Clostridium difficile infection symptoms to reduce the risk of symptom relapse. A national business case is in development to support the use of Fidaxomicin as a first line treatment for patients with Clostridium difficile infection. Achieved: Hand Hygiene compliance across NHS Highland is consistently over 95% Continue to improve empirical and prophylactic antimicrobial prescribing in Raigmore and the Rural General Hospitals Continue to monitor appropriateness of Proton Pump inhibitor prescribing across NHS Highland with a view to achieving a reduction. Antimicrobial Management team, prescribers and Lead Nurses Prescribers and Lead Nurses Achieved: The continued monitoring of the 3 national indicators shows that despite expected seasonal fluctuations in prescribing NHS Highland is compliant overall and has seen a decrease in prescribing rates of antibiotics. Achieved: NHS Highland is compliant overall and has seen a decrease in prescribing rates of proton pump inhibitors. The appropriateness of proton pump inhibitors is reviewed local Pharmacists monthly. 2015/ Annual work plan 4

5 1.2.7 Reduce GP prescribing of Clostridium difficile related antimicrobials where possible Continue to monitor or /sustain compliance above 90% for environmental cleanliness and fabric maintenance Ensure local healthcare associated infection standard monitoring tool is in line with National guidance, and annual local monitoring occurs across all hospital sites. Antimicrobial Management team, prescribers and Lead Nurses Achieved: The level of GP prescribing has been maintained at a low rate, despite a small rise being reported nationally. The Control Manager and Executive Lead for and Control met with the Pharmacy Lead to discuss improvement actions. Engagement with GPs continues through the Antimicrobial Management team, and local Pharmacists. Achieved: Overall average of 96% cleaning and 96% for estates monitoring continues to be maintained. and prevention Achieved: The healthcare associated infection monitoring tools has been updated to reflect national guidance issued in As a minimum, annual monitoring occurs across all hospital sites; conducted by a multi-disciplinary team of staff from the Operational Unit. 2. & Control Staffing resource: To ensure that all staff disciplines of staff across Highland have access to Specialist & Control guidance By reviewing where infection prevention & control input is required in each operational unit, and exploring how this can be delivered effectively and prevention by Control In Progress: A review of where infection prevention and control staffing resource is required is underway. A benchmarking exercise with other NHS Boards has been completed The IPCT are to undertake job planning exercise in and information from this will be discussed in June. This action will continue in /2017. The revised target date for this is Sept. 2015/ Annual work plan 5

6 Manager By reviewing the role of the & Control Nurse ensuring time is built into job plans for staff s own development needs By ensuring the role of the & Control Link Practitioner is in order to empower them to cascade information to their colleagues. and prevention by Control Manager / Alison Hudson Achieved: The nurses are fully compliant with mandatory and continuing professional development requirements. Achieved: Control and link practitioner roles are well established across the healthcare settings in NHS Highland. Work continues to continuously promote and support these practitioners in their link roles. The continue to hold link practitioner days for community and acute staff which are well attended. 2.2 To review the use of & Control Doctor resource and agree a model of sustainable provision with the Operational Units By identifying where infection prevention & control doctor input is required in each operational unit, exploring how this can be delivered. Head of microbiology by IPC Lead Doctor & IPC Staff turnover in the microbiology department has resulted in the loss of the Clinical Lead; whilst recruitment to this post is underway, the impact of this vacancy is significant. A Locum Consultant is in place whilst recruitment is underway. RED 2015/ Annual work plan 6

7 Executive Lead, Executive Lead for The process to identify where Doctor input is required has been slow to progress due to other priorities. A job planning exercise is now underway in order to review the existing medical service. This will form part of the overall service review (see 2.1.1). This action will continue in /2017. Revised target date is to be set 3. & Control is everyone s business; Embed the importance of & Control into everyday practice By implementing a rolling programme of Standard Control Precautions compliance monitoring By ensuring that there is & Control input in all new builds/refurbishments as per HAI-Scribe. Supported & Control Lead Nurses, Nurses, Estates team Achieved: A rolling programme of Standard Control Precautions compliance monitoring is established across all clinical areas, including care homes. In Progress: Early engagement of the has been good in some major planned works and HAI-Scribe has been fully implemented. However consistent engagement in all works is yet to be achieved and therefore this action is rag rated amber. Doctor and Control Manager now regularly attend the estates management meeting to ensure early engagement. Estates have also improved attendance at Control Improvement Group. HAI-Scribe Compliance is being monitored, and until a level of consistency is achieved. This will 2015/ Annual work plan 7

8 3.1.3 By identifying and reporting noncompliant sinks & poor fabric condition By auditing compliance with NHS Scotland mandatory screening policy for MRSA. Minimum compliance required is 90%. Lead Nurses, Nurses, Estates team IPC Surveillance team / Lead Nurses continue to be monitored. This action will continue in /2017. Revised target date Dec16. Achieved: All non compliant sinks have been identified. A robust rolling programme is in place to identify poor fabric conditions. The Operational Units are progressing replacement sinks and repairs based on local risk assessment. In Progress: NHS Highland is currently 78% compliant and is working toward the 90% compliance by focusing on improvement of completion of documentation. The next quarter of data will be available April. This action will continue in /2017, and be monitored through ICIG. Revised target date Sept. 4. HEALTHCARE ASSOCIATED INFECTION Standards: Embed the process and governance arrangements for HAI Standards Monitoring By ensuring there is a programme of healthcare associated infection standards monitoring visits in each Operational Unit By ensuring that there is a system in place to escalate any actions which cannot be progressed through the line management structure and via the Control Improvement Group & Control Achieved: There is a programme of healthcare associated infection standards monitoring visits in each Operational Unit this includes hospital wards, care homes, learning disability facilities etc. Achieved: Each hospital has its own action plan which is monitored through local processes and reports to the local & Control Groups. Risks are managed through risk registers and escalated to Control Improvement 2015/ Annual work plan 8

9 & Control Group as deemed required Lead Nurse. 5. HEALTHCARE ASSOCIATED INFECTION Education: To ensure Patient/Service Users safety is achieved in relation to & Control by standardising HAI education and training, targeted at different staff groups across NHS Highland in Hospitals; Community; Primary Care; Care Homes; Care at Home; Adult Day Care Centres; Learning Disability; Bank Staff; Social Work Staff; Volunteers and Contractors By ensuring that staff are compliant with their mandatory infection prevention and control training requirements as per the Healthcare associated infection education strategy By ensuring that there is a robust local system for recording mandatory healthcare associated infection training undertaken by staff Dec 2015 by Business Support Manager learning and Developme nt / Control Manager by Business Support Manager learning and Developme nt / Control Manager In Progress: A Board wide system to monitor training completed by staff is under development. Therefore this action is amber until this system is in place to provide Board assurance. This action will continue into /2017 and be monitored through the educational Sub-governance group and ICIG. In the interim all training is monitored locally. Lead Nurses assess current compliance with mandatory healthcare associated training requirements, through local governance systems and as part of local HAI Standard Walk rounds. Achieved: see To ensure our healthcare providers who Lead Achieved: Training continues across all healthcare 2015/ Annual work plan 9

10 work within care homes and care at home are involved in healthcare associated infection training Nurses, Nurses, 6. Surgical Site s 6.1. To reduce elective colorectal surgical site infections year on year 6.1 By the development and adherence to the Colorectal infection reduction action plan Colorectal Supported & Control areas as per the requirements in the Statutory and mandatory training prospectus. As per a system to monitor all staff training is underway. Achieved: Colorectal action plan has been developed and adherence is monitored. The local aim to achieve less than 10 % colorectal SSI has been achieved (9.7% Oct-Dec15). 6. Surgical Site s 6.2. To reduce elective and emergency Caesarean Section (C-Section) Surgical Site s year on year 6.2 Through monitoring surgical site infection rates and practice. Achieved: Elective C-Section data shows SSI rate for % compared to 1.4% in Obstetric & Midwifery s Supported & Control 6. Surgical Site s 6.3. To reduce Orthopaedic Surgical Site s year on year. 6.3 Through monitoring surgical site infection rates and practice. Orthopaedic Supported Emergency C-Section data shows SSI rate for % compared to 2% in Variation continues in the SSI rate for emergency C-Sections as it is acknowledged that the low number of operations (denominator data) has a greater impact on the overall percentage figure. End of year 2015 data is not available till late April 2015 data is not available till late. Total hip replacement SSI rate 2014 is 0.66% compared to 0.25% in / Annual work plan 10

11 6.4 Comply with all HPS mandatory surveillance By ensuring the continuation of data collection and submission of mandatory surveillance To progress the rollout of the ICNet electronic surveillance system to include Argyll & Bute CHP and with the addition of the admission, discharge and transfer tracking programme Sept & Control Control Manager Supported & Control Control manager NHS Highland / NHSGGCC / Lead Nurse A&B Hemiarthroplasty SSI rate for 2014 is 1.7% compared to 2.9% in Fracture neck of femur SSI rate for 2014 is 0.7% compared to 1.8%. Achieved: NHS Highland undertakes all Health Protection Scotland mandatory surveillance, as outlined in DL (2015) 19. As of April E Coli bacteraemia surveillance will become mandatory. The National Point Prevalence Survey will also occur this year. These additional mandatory surveillance fields will have a significant impact on infection prevention and control and admin resource, and this workload is being considered as part of the wider Control and service review. In Progress: This is now being progressed to be completed by April. This is rag rated amber due to the associated risk being placed on infection prevention and governance due to the current reliance on manual data sharing and input. A request has been made to the Head of e-health to obtain a timeframe for this. This action will be carried forward in to /2017, with revised target April. 7. Support antimicrobial management team to monitor and improve antimicrobial prescribing compliance To continue to monitor the antimicrobial Antimicrobi Achieved: see sections and NHS prescribing and proton pump inhibitor usage across NHS Highland al manageme Highland is compliant overall and has seen a decrease in prescribing rates of antibiotics and 2015/ Annual work plan 11

12 7.1.2 By ensuring antimicrobial prescribing is in line with National policy, and monitored through the national prescribing indicators nt team proton pump inhibitors. This data is taken from 5 data points (June to Nov 2015). NHS Highland guidance is in line with National policy and monitored through the 3 national indicators. 8. Water Safety: Through the Water Safety Group, ensure NHS Highland has robust and consistent arrangements in place for the safety of the water systems in NHS Highland comply with legal duties and relevant guidance By ensuring water flushing guidelines are in line with National guidance, and are fit for purpose for local implementation By ensuring the implementation and monitoring of compliance with Control of Legionella guidance. Water safety group Supported & Control Water safety group Supported & Control Achieved: Procedures for the prevention of waterborne infection which include risk assessment, analysis and planned preventative maintenance are in place and in line with national guidance. The current standard operating procedure for water flushing has been updated through the Water Safety group to ensure it is fit for implementation across all care settings. Achieved: The Water Safety Group continues to monitor compliance with the Control of Legionella guidance within the Operational units to ensure water quality is sustained. 9.Cleaning and Decontamination; To support Domestic Services to achieve and maintain 90% cleaning compliance across NHS Highland By ensuring the development and NHS Achieved: The NHS Highland cleaning compliance 2015/ Annual work plan 12

13 implementation of Standard Operating Procedures (SOPs), for room cleaning are in place By the development and implementation of Domestic Services Standard Monitoring Procedures By assessing Domestic Services staffing levels based on the agreed SOPs within Raigmore Hospital. Highland Professional Lead for Soft Facilities Services NHS Highland Professional Lead for Soft Facilities Services NHS Highland Professional Lead for Soft Facilities Services audits consistently achieve over 90%. Room cleaning SOPs are in place and regularly monitored. Achieved: Domestic services standard monitoring procedures are in place across the NHS Board. The domestic monitoring team assess cleanliness against the National Cleaning Specifications and report exceptions to the Senior Charge Nurse. In progress: Domestic services staffing levels in Raigmore have been assessed and recommendations have been discussed and agreed with the Raigmore Senior management team. Recruitment is underway, and this item will remain amber until the posts are in place. This work is overseen Lead for Soft Facilities and progress updates are provided to Control Improvement Group quarterly. This action will be carried forward in to /2017, with revised target April. 9.2 Improve compliance with all aspects of decontamination By ensuring that there are systems, processes and facilities in place for the safe reprocessing of reusable high risk equipment. NHS Highland Decon - tamination Achieved: The Sterile Services Department ensures and monitors compliance on the safe reprocessing of high risk reusable equipment throughout NHS Highland. 2015/ Annual work plan 13

14 9.2.2 By ensuring that there are systems, processes and facilities for safe decontamination of low risk reusable equipment Group NHS Highland Decon - tamination Group Information is presented to the Decontamination group to provide assurance that the systems in place are correct. Achieved: The decontamination processes undertaken on low risk reusable equipment are monitored thorough the HAI walk rounds, and through the Standard Control Precautions audit programme. The facilities used to decontaminate and store low risk reusable equipment in the community have been reviewed and recommendations made for improvement. 10.Catering Services; To support Catering Services & Clinical Staff to ensure food safety from production to delivery is embedded within NHS Highland Through education & training of food handlers in their mandatory training requirements By ensuring that there is a robust system of recording of what training has been undertaken NHS Highland Professional Lead for Soft Facilities Services Achieved: All advanced food handlers have received food safety training as per the Statutory and Mandatory training requirements. Training data is recorded Hotel Services Manager (Quality and Training), and compliance data is presented at the Hotel Service Managers group. 11.HEALTHCARE ASSOCIATED INFECTION Scribe; Ensure optimum environment to minimise risk of infection Ensure compliance with HAI-Scribe through monitoring of minor works Estates and Lead nurses for Operational units In progress: It has been acknowledged by Estates that the current Maximo System is not providing a robust system for monitoring compliance for Minor works. As a result an upgrade has occurred. The initial go live date in Dec 2015, was delayed and 2015/ Annual work plan 14

15 testing commenced in Jan. This upgrade will create a system fit for purpose. Status Reports will then be available to the Senior Charge Nurses &. This action will continue in /2017 with progress monitored through Control Improvement Group. Revised target date of Sept. 12. Waste management (including Sharps); Through the waste management group and Health and Safety Committee ensure NHS Highland has robust and consistent arrangements in place for the safe handling of waste (including sharps), and complies with the SHTN Ensure compliance with National Waste Guidance SHTN-3 regarding waste segregation by: Implementation of waste policy Education & training Conducting waste audits 12.2 Support the rollout of safety engineered devices across NHS Highland Feb Waste Manageme nt Officer, Lead Nurses, Health and Safety, Procureme nt, Occ Health by Ali In progress: NHS Highland is compliant with safe handling of waste regulations. Following the publication of national guidance SHTN-3 on waste; new waste guidelines and waste posters for staff have been produced, and are awaiting print. This action is currently rag rated amber as dissemination of supporting guidance for staff has not yet occurred. Training is in place via arrangement with the Waste Officer, and aspects of training are incorporated in Health & Safety and Control training. The development of a mandatory education programme to support all staff in the long-term is underway. Waste audits occur as per the NHS Highland waste action plan. This action will continue in /2017 and be monitored through the Waste Steering Group and Health and Safety Committee. Revised target date of Sept. Achieved: The roll out of safety engineered devices by procurement has been implemented with the support of the Operational Units, 2015/ Annual work plan 15

16 12.3 Ensure compliance with the policy for safe handling of sharps Cattanach, Health and Safety, Occ Health and prevention by and Health and Safety team team, Health and Safety, and Occupational Health, and is reviewed through the Workplace Hazard group and Control Improvement Group. Achieved: NHS Highland is compliant with the policy for safe handling of sharps. Compliance with safe handling of sharps is monitored through audit and review of Datix data. The local HAI-walk rounds monitor compliance with the safe handling of sharps; and as an additional assurance an audit of sharps compliance occurs through an external company. Audit data identifies compliance. 2015/ Annual work plan 16