The State Hospitals Board for Scotland. Infection Control Annual Report. 1 April March 2017

Transcription

1 The State Hospitals Board for Scotland Infection Control Annual Report 1 April March 2017 APPROVED BY DATE Infection Control Committee 25/5/17 Clinical Governance Committee 11/5/17 1

2 SECTION CONTENT PAGE 1 Introduction 3 2 The Infection Control Service 3 3 Summary of Infection Control Activity (i) Audit (ii) Education and Communication (iii) Antimicrobial Management (iv) Outbreaks / DATIX Incidents (v) Seasonal Flu Review / Development of Policies and Guidance 13 5 Conclusion 13 Appendices Appendix 1 Infection Control Programme of Work Appendix 2 Infection Control Audit Programme

3 1 INTRODUCTION The State Hospitals Board is responsible for the prevention and control of infection within its services to minimise the risk of healthcare associated infections to patients, staff, carers, volunteers and visitors. The State Hospital is not considered to be high risk for infection or cross infection; however the employment of evidence based protocols to assist clinical practice to ensure a clean and safe environment is an integral part of our overall clinical governance agenda. This Annual Report and Programme of Work outlines the activities and accomplishments relating to infection prevention and control. This is submitted to the Infection Control Committee (ICC) for approval and will then be forwarded to the Chief Executive (via the Clinical Governance Committee) and senior members of hospital staff. The document is also available to all staff via the intranet: spx 2. THE INFECTION CONTROL SERVICE The Infection Control Committee (ICC) promotes the highest standards of practice within the organisation for infection prevention and control, ensuring compliance with the Healthcare Improvement Scotland (HIS) Healthcare Associated Infection (HAI) 2015 standards. The Infection Control Committee supports the development, implementation and ongoing monitoring of Infection Control Activity throughout the State Hospital in line with the Infection Control Programme of Work. The ICC monitors the programme on a quarterly basis, with any changes to the content being identified by the Advanced Practitioner for Infection Control (APIC) and subsequently approved by the Committee. Thereafter any significant change to the programme will be reported to the Senior Management Team in the same way as for the programme approval. Good practice in infection prevention and control clearly does not rest solely within the remit of the Committee. Every member of staff has a responsibility to prevent healthcare associated and blood borne virus infections (BBV) in the State Hospital and are accountable for their actions in relation to this. Outwith this report the Infection Control Committee respond to a number of items as they arise. These can take the form of National direction (HPS, HFS, NES etc), HEI recommendations or hospital requests / queries. Throughout the year the following areas have been raised HEI recommendation regarding the wearing of wrist watches this resulted in a full uniform review Raw food and eggs being brought in and being cooked in the ward kitchens Review of the outbreak management plan Review and renewal of the Service Level agreement with NHS Lanarkshire for the Infection Control Microbiological / Infection Control Doctor services Water safety group review of the risk assessment Environmental Health Inspections of main kitchen and therapeutic kitchen Review of Infection Control Committee membership The APIC is responsible for managing the Infection Control Service on a daily basis (supported by the Director of Nursing and AHPs) and provides an informal out of hour s service for urgent enquires. Membership of the ICC complies with the requirements of the Scottish Infection Control Manual and NHS Healthcare Improvement Scotland (NHS HIS) Healthcare Associated Infection Standards (HAI) (2015). In the event of an outbreak i.e. two or more wards closed simultaneously a subgroup of the Infection Control Committee meet as the Outbreak Team. Advice can also be sought from the on-call Consultant Microbiologist through Wishaw General Hospital switchboard (all contact details available on intranet). 3

4 The core Infection Control activities relevant to the State Hospital include: Outbreak Management Blood Borne Virus (BBV) Surveillance - Manage Hepatitis B vaccination programme Alert organism / condition surveillance Audit Education, training and communication Policy development and monitoring Specialist advisory role The implementation and management of the Infection Control Programme will be supported, monitored and reviewed quarterly by the ICC. The Infection Control Programme of Work for can be viewed in Appendix 1. The vacancy of the post of Hand Hygiene Co-ordinator / Quality Improvement Facilitator for Healthcare Associated Infection (HAI) prompted a review of the Infection Control Service and the key priorities for the year. 3. SUMMARY OF INFECTION CONTROL ACTIVITY (i) Audit Performing regular audits and providing feedback helps to raise awareness of any infection prevention and control issues at all levels throughout the hospital. Our audit results demonstrate sustained improvement in practice and will motivate staff and patients to maintain this improvement. The State Hospital uses a local audit database which enables all audit activity to be held centrally and action plans to be published. The action plans are then disseminated to the key stakeholders for follow up; this enables a more robust system of audit to be implemented with the organisation. The Infection Control audits undertaken by the Infection Control Service (Appendix 2) are predominately dictated by the National Standard Infection Control Precautions (SICPs) Audits. These previously were undertaken by the Quality Improvement Facilitator for HAI; however since this post became vacant this role was incorporated into the role of the APIC. As a consequence the HIS Improvement Team (HISIT) for HAI assisted the APIC to review the current audit program to ensure that a robust audit system was in place that complied with the HAI Standards. This review followed the Quality Improvement model using small tests of change. A key change was the merging of some Infection Control audits with the Health and Safety econtrol Book, namely the Healthcare Waste and the Workplace Inspection Checklist. Both of these audits are now undertaken by the Senior Charge Nurse (Control Book Holder) or their deputy with quality assurance check by the APIC on a quarterly basis. A full audit will be undertaken by the APIC the frequency of which will be determined by the Infection Control Committee in May The main activities from the audit programme include: Clinical Waste and Sharps Audit As previously stated the APIC has worked in conjunction with the Risk Management Team Leader and HIS IT to streamline and combine the Clinical Waste and Sharps Audit with the Health and Safety econtrol book. 4

5 This improvement project pilot began during May / June with subsequent roll out to the rest of the hospital during the second quarter (July September). The only quality improvement audits that were undertaken were during the pilot phase of the project (see Chart 1). Chart 1: Area Audited % Compliance Iona Iona Iona Infection Control Environmental Audits& Cleaning Services The significant water leaks and subsequent water damage caused by heavy rain was a result of latent defects. This appears to have been rectified by the contractor responsible; however the remedial damage to paintwork etc requires attention. The Infection Control Committee will continue to monitor the situation. A common theme noted throughout the Senior Charge Nurses Rapid HEI audits related to the condition of the carpet and furniture. This has been addressed as part of a rolling program throughout the year. As previously stated the APIC has worked in conjunction with the Risk Management Team Leader and HIS IT to streamline and improve the Health & Safety Workplace Inspection Checklist located within the econtrol book. This has resulted in the removal of the Senior Charge Nurses Rapid HEI audits and the SICPs Control of the Environment audit. The Workplace Inspection Checklist will continue to be undertaken by the Senior Charge Nurse (control book holder) on a quarterly basis with the APIC undertaking quality assurance audits. The housekeeping department continue to undertake the NHSScotland National Cleaning Services Specification monitoring which provides the assurance that every room (as a minimum requirement) is audited not only for cleanliness but also estates and user issues on an annual basis. The results of these audits have continued to be in the green which indicates a result of 90% or above. HAI SCRIBE documentation was reviewed by Health Facilities Scotland in 2014 and we continue to use this for any new or remedial structural or maintenance actions that are identified within the hospital. Bed Mattress Audit It is known that damaged mattresses can harbour micro-organisms and be a potential cause of cross-infection. The APIC continues to undertake an annual quality assurance audit of all mattresses across the hospital. The bed mattress audit is undertaken to ensure compliance with national guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) relating to all types of bed mattresses (MDA/2010/002). The results of the mattress audits demonstrated a continued improvement on the cleanliness of the mattresses however the mattresses that required to be replaced was due to them failing the compression test (of which there were six). This is only to be expected given the increasing obesity problem within the organisation and the low turnover of patients. 5

6 A new guidance document has been produced which outlines the procedure for both housekeeping and nursing staff; this provides a clear account of the product and the procedure to be used when a patient vacates a bedroom. Blood Borne Virus (BBV) Audits A change to the admission and annual BBV risk assessments in 2015 ensures that we are complementing NHS Lanarkshire and SALUS protocols. The Clinical Effectiveness department continue to audit the BBV risk assessment data as part of their Variance Analysis Tool (VAT) reviews. 96% of patients had a BBV admission risk assessment completed as part of the admission process during the year. An audit of the annual risk assessments and associated documentation relating to the VAT requirements will be audited in May All patients are offered the opportunity to be tested and are provided with information on Hepatitis B, C and HIV and the associated risk factors within 90days of admission. Almost 12 % of the patients tested have a blood borne virus. Chart 3: Patients Number Not seen by APIC 5 Out with 90 days 0 Seen and refused testing 23 Tested 86 Under care of ID consultant 10 The patients are also offered the opportunity to be vaccinated against hepatitis B. The Medicines Committee have supported the rapid vaccination schedule which means that patients can complete their vaccination program within two months as opposed to 6 months. It is also worth noting that as from April 2017 blood borne virus screening will be incorporated into the admission bloods with a follow up at six months and then annually thereafter. Chlamydia and Gonorrhoea will also be part of the admission screening. Hand Hygiene Compliance Audits The hands of staff are the principal method by which micro-organisms are transmitted to patients. Hand washing is widely acknowledged as being one of the most important ways of preventing the spread of infection within healthcare settings. The State Hospital has supported the Scottish National Hand Hygiene Campaign by undertaking hand hygiene audits throughout the site to measure the success of the campaign which started in Since the National Campaign ended monitoring of hand hygiene practices has continued locally by reporting results through the quarterly HAIRTs to the Infection Control Committee and the Senior Management Team. The audit results are currently displayed within the Hubs, Skye Centre and staff reception. The audit results are displayed by area and discipline hospital wide. This highlights the differences between each area and where improvement is required. Since August 2016, in an attempt to increase the number of audits submitted the APIC has reviewed the frequency and method of audit reporting. This is now reported monthly to each Senior Charge Nurse and displayed in each hub. A focus for this year will be to increase hand hygiene compliance within the Skye Centre. 6

7 Chart 1: % Audits Submitted by Quarter % Audits Submitted Arran Iona Lewis Mull Health Centre Quarter 1st 2nd 3rd 4th Area Chart 1 shows the percentage of audits submitted during the year. There has been a general increase in the audits submitted during quarters 1-3; however this has dropped in the last quarter. Chart 2: % Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hand Hygiene % Compliance Hospital Wide 01/04/ /03/2017 Arran Iona Lewis Mull Health Centre Area 1st 2nd 3rd 4th Chart 2 demonstrates the overall compliance across the hubs. It is reassuring to note that the health centre consistently achieves 100% compliance. 7

8 Chart 3: % Compliance Among Discplines Across the Site 1st April st March 2017 % Compliance Nurses Doctors AHP Other Psychology Facilities Discipline Arran Iona Lewis Mull Health Centre Chart 3 shows the % compliance across each discipline within the Hubs and Health Centre. It is reassuring to note that nursing staff have the highest hand hygiene compliance with an average score of 95% and the other disciplines have an average of >83%. (ii) Education and Communication Staff education in the general principles of infection control is of great importance. The hospital aims to sustain the low incidence of HAI and manage BBV Infection effectively and ensure safe working practices. The State Hospital has a three year HAI Education Training Plan which is reviewed by the Infection Control Committee 6monthly. The APIC continues to participate in the corporate Health and Safety Training Programme for clinical / non clinical staff of which there were two days scheduled this year. The APIC also has involvement in the medical staff rotational induction programme. The topics covered include the infection control structure, BBV awareness, hand hygiene, the management of patients with loose stools and the management of clinical waste. Education continues to be an essential part of the role of the APIC by contributing to the induction programme for all new staff; the development and review of online learning material and the provision of an informal in-service education whenever there is a clinical need; this often follows a request from wards or departments. Education and Communication have been delivered in various forms across the hospital e.g. promotional leaflet campaigns, interactive campaigns, dedicated newsletters to name a few. Promotion for campaigns such as World Aids Day, World Hepatitis Day, and Varicella awareness occurred during the last year by way of poster campaigns and the distribution of leaflets. This is also supplemented by the intervention of the APIC during BBV assessment work at 90days post admission. Cleanliness Champion Programme The Cleanliness Champion training programme was developed by NHS Education for Scotland as outcome of the Scottish Government Action Plan (2002) preventing infections acquired while receiving healthcare. The overall aim of this Cleanliness Champion Programme is to train staff to a level that will empower them to promote and maintain a culture at work in which infection prevention and control is given the highest regard. 8

9 The Hospital has significantly exceeded the initial target set out by the Government in HDL 2005 (7) of one Cleanliness Champion per ward area. Following Healthcare Environment Inspections it was recommended that all Nursing Team Leaders undertake the Cleanliness Champion programme, we negotiated with National Education Scotland that they could undertake a modular approach and complete five of the modules. The information contained in the other four remaining cleanliness champion programme modules are included in our own online mandatory modules for all staff. All our Nursing Team Leaders and Senior Charge Nurses (in post before February 2017) are registered on the Cleanliness Champion Programme. It is expected that they will all complete the five modules identified regardless if they are in a substantive or developmental role. This is included in the HAI Training Plan and progress will continue to be monitored by the ICC biannually. From November 2016 formal registration by NES for the Cleanliness Champion program ceased. This will be replaced by the Scottish Infection Prevention and Control Education Pathway (SIPCEP). The Infection Control Committee will agree on the most appropriate way to take this forward. Hand Hygiene e-learning Programme This programme is mandatory training for all staff within the Hospital. During the year (689 ) completed this year = 84% of staff 19 staff have never completed (all new starts) 119 staff are overdue their refresher training It is expected that all new staff (including those with Service Level Agreements e.g. Pharmacy, Advocacy) within the organisation will complete this module within 3 months of employment. Royal Environment Health Institute of Scotland (REHIS) Elementary Food Hygiene Training Poor hygiene during food preparation and handling procedures can put patients and staff at risk. Harmful bacteria that cause food poisoning can spread very easily and can lead to serious illness or even death. The Infection Control Committee approved (supported by the Learning and Development Manager) a tailored approach to Food Hygiene Training. This approach will ensure that staff will be trained to a level commensurate with their role. There will be a combination of both face to face and online training sessions depending on the level of need. Occupational Therapists, those in a position of responsibility i.e. Senior Charge Nurses, Nursing Team leaders and those who are directly involved in food preparation i.e. Catering staff will still require to be trained to the REHIS Elementary Food Hygiene standard. Those who are responsible for the service of food at ward level will be required to complete the online module (498 staff. 64 completed this year = 13% of staff group (not mandatory for all staff). 41 staff have never completed No refresher required There was one REHIS Introduction to Food Hygiene (10 patients), and one REHIS Elementary Food Hygiene (9 patients) course available for patients during the past 12 months There were two REHIS Elementary Food Hygiene Courses for staff scheduled; however one was cancelled due to staffing resources during the past 12 months. The following staff completed the training during this year. 1 Senior Charge Nurse 1 Nursing Team Leader 1Occupational Therapist 9

10 There are further REHIS Introduction and Elementary Food Hygiene courses for patients and staff programmed for the incoming year. Blood Borne Viruses (BBV) Training Module The module is open to all staff but is of particular relevance to clinical staff involved in direct patient care. This is a mandatory module for clinical staff with refreshers being undertaken biennially (499). 154 completed this year = 31% of staff group (not mandatory for all staff) 63 staff have never completed (mix of new starts and others) 48 staff are overdue their refresher training This is a significant improvement from last year when there were 139 staff that are required to complete the module but hadn t. Infection Control training is monitored by the Learning Centre and reported directly to line managers. Quarterly reports are presented to the Infection Control Committee. Equality and Involvement / Patient Partnership Group The APIC attends the Patient Partnership meetings as required to discuss any Infection Control issues that patients may have. Infection Control Updates Infection control updates continue to be disseminated throughout the year. These updates provide information on infection control news and developments, both locally and nationally. The information is conveyed via the hospital intranet, staff bulletins, Vision magazine and through internal s. (iii) Antimicrobial Management Inappropriate use of antibiotic medication can have a negative impact on individual levels of resistance and vulnerability. The State Hospital has an established Service Level Agreement with NHS Lanarkshire for the provision of sessional input from an Antimicrobial Pharmacist who is also a member of the State Hospital Infection Control Committee. The Empirical First Line Antibiotic Policy for Primary Care has been adopted for use by the State Hospital. The Infection Control Committee monitors the results of the audits led by the Antimicrobial Pharmacist in conjunction with members of the Clinical Effectiveness Department. The State Hospital is represented in the Lanarkshire Antimicrobial Management Committee by our Antimicrobial Pharmacist. Currently the Hospital is compliant with all National / Local Antimicrobial Prescribing Policy and Guidance, with a sustained minimal spend per quarter on such drugs. Antimicrobial use within The State Hospital is monitored by quarterly retrospective analysis and annual prospective audit. The Infection Control Committee recommended that all staff nurses should complete the NES Antimicrobial Workbook; this is in line with the rest of NHS Scotland. This change will come into effect from April (iv) Outbreaks / DATIX Incidents The State Hospital uses the DATIX reporting system to monitor and examine infection control incidents; this will highlight concerns and emerging trends. 10

11 There were a total of 36 incidents recorded under the category Infection Control during this period (an increase of five from last year). Category Number Vomit Diarrhoea 24 Other 2 Exposure to bodily fluids / Faeces 2 Exposure to bodily fluids / Urine 3 Clinical Waste / Other 2 Exposure to bodily fluids / blood 2 Exposure to bodily fluids / Spitting 1 In addition to the primary category of infection control incidents there were 55secondary infection control incidents. This is a decrease on the previous year with 61 being recorded. Extra Fields April 2016 March 2017 April 2015 March 2016 April March 2015 Exposure to Bloods and bodily fluids Exposure to Faeces Exposure to spit Clinical waste Needlestick Total Over the past year, one ward was closed twice due to vomiting and diarrhoea. During this timeframe (nine days) eight patients and four staff were affected across the site. The cause of the outbreak was inconclusive, as no samples were provided, but it was thought that viral gastroenteritis was the likely culprit. The majority of patients had symptoms of either diarrhoea and / or vomiting which lasted for hours, none of those affected required treatment. Prompt and effective infection control practice prevented the spread of this across the site and this is a credit to all staff and patients. In addition, The State Hospital Infection Control Committee continues to monitor flu activity including vaccination rates and continues to review the operational Pandemic Influenza Plan according to current information and annually as part of resilience planning. From the 8 th December to 1 st March the State Hospital quarantined their birds and pigeons. This was in response to advice from DEFRA regarding the confirmed cases of avian flu across the UK and Europe. (v) Seasonal Flu Vaccination Programme The State Hospital continues to offer seasonal flu vaccination to both patients and staff. The staff vaccinations can be obtained either in Occupational Health (throughout the campaign) or at designated flu clinic (over a two week period) held in the Family Centre. There was a significant improvement in the uptake of the vaccination this year (Chart 5). 11

12 Chart 5: 2015/ /2017 Total staff vaccinated 181 (27.5%) 224 (33.7%) Direct patient care 21.1% 27% Nursing staff 15% 19% Direct Clinical Care 21.1% 27.5% Non Direct Clinical care 35.9% 40.1% This year, 75 patients (66.3%) of our current patient population accepted a flu vaccination. The previous uptake rates for 2014 and 2015 respectfully were 62.9% and 63.2%. 4 REVIEW / DEVELOPMENT OF POLICIES AND GUIDANCE The State Hospital Board continues to use the NHS National Infection Control Manual supplemented by its own electronic infection control policies and guidance l which manages local issues. Policies are influenced by those developed from NHS Lanarkshire and emerging information received from Health Protection Scotland. The policies are reviewed by the Infection Control Committee when required and as new guidance emerges. In light of the Vale of Leven recommendations the review of these polices will change from triennially to biannually or earlier if legislation / emerging guidance dictate. All new and reviewing of the Infection Control Polices will be Equality Impact Assessed prior to approval and publication. 5 CONCLUSION Infection control and prevention will continue to be monitored through the Board s Clinical Governance Structure. Good infection control and prevention practice is not the sole responsibility of The State Hospital Infection Control Committee. Every member of staff has a responsibility to reduce the likelihood of healthcare associated infection and is accountable for their actions in relation to this. The 2 key indicators to support this statement are firstly, the overall level of cleanliness of the Hospital (as indicated by National Compliance for Domestic Monitoring and by HEI inspections) and secondly no significant outbreaks. The State Hospital s current record on both indicators suggests that staff are responding positively to the challenge. 12

13 THE INFECTION CONTROL PROGRAMME OF WORK & AUDIT PROGRAMME 1 APRIL MARCH 2018 Appendix 1 This programme has been developed on behalf of the State Hospital by the Advanced Practitioner for Infection Control, the Infection Control Committee and other key stakeholders. It is subsequently endorsed by the Senior Management Team and Clinical Governance Committee. The implementation and management of the Infection Control Programme will be supported, monitored and reviewed quarterly by the Infection Control Committee The Committee relies on all professions working together to promote good prevention and control of infection. Progress on this work plan will be provided at quarterly Infection Control Committee meetings and areas of concerns to Senior Management Team meetings. Prevention and Control of Infection does not rest solely within the domains of the Infection Control Committee, everyone has prevention and control of infection responsibilities. The Infection Control Committee will co-ordinate the delivery of this program of work. Local managers must take a lead in ensuring interventions are implemented and monitored at a departmental level to ensure a safe environment for patients staff and visitors. The content of the programme has been influenced by: Scottish Government -3 year delivery Plan for HAI HIS HAI Standards (2015) HEI Self Assessment and Action Plan Leading Better Care -Senior Charge Nurse Framework Scottish Patient Safety Programme Hand Hygiene Campaign CEL (2009)5 National Cleaning Services Specifications (HFS) The annual Infection Control Programme details the main activities of the Infection Control Team / Committee during the incoming year April 2017 March These include: Ensuring that appropriate resources are made available to support infection control activities. Having in place policies and guidance for management of infection control across the organisation. Reviewing and improving infection control arrangements where necessary. Ensuring that staff receive relevant training in the prevention and control of infection. Communicating infection control information to all relevant parties. Working with other stakeholders to improve surveillance. All healthcare workers must be aware of infection prevention and control issues in order to take responsibility both individually and as part of a team for the maintenance of excellent standards of care. IMPLEMENTATION OF THE INFECTION CONTROL PROGRAMME The APIC plays a major role in the implementation of the Infection Control Programme. Any areas of concern will be brought to the attention of the Infection Control Committee. An analysis of any potential resource implications in the development and delivery of the Programme will be submitted to the Senior Management Team as part of the Local Delivery Plan cycle. CONCLUSION Infection prevention and control is a high priority for The State Hospital and will continue to be monitored through the Board s Risk and Governance Structure. Infection Prevention and Control 13

14 can only be successful through the employment of an active organisation wide programme with the commitment of all staff in The State Hospital. INFECTION CONTROL PROGRAMME (Attached) The timescales identified for activities outlined in this programme may be subject to change depending on unscheduled work and clinical activity. Any deviations from the programme will be monitored by the Infection Control Committee. 14

15 INFECTION CONTROL PROGRAMME OF WORK Standard 1: Leadership in the prevention and control of infection Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 1.1 Build and strengthen Advanced Practitioner for Infection Control portfolio 1.2 Enhance multi disciplinary working to reduce duplication of work and increasing efficiency 1.3 APIC to continue to represent The State Hospital on national working groups 1.4 Develop performance indicators for the Infection Control Committee 1.5 Assurance - Participation in leadership walkrounds by Senior Management and members of the Hospital Board

16 Standard 2: Education on Infection Prevention and Control is provided and accessible to all healthcare teams to enable them to minimise infection control risks that exist in care settings Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 2.1 Participate in the State Hospitals Health & Safety training day 2.2 To continue to support the APIC role as HAI Education Lead 2.3 Review the existing education program in line with NES Scottish Infection Prevention and Control Education Pathway (SIPCEP) 2.4 Monitor and report quarterly to the ICC infection control training uptake on Hand Hygiene, Food Hygiene and BBV modules 2.5 Continue to support the further education / development of the APIC and other members of the Infection Control Committee 2.6 Deliver x2 REHIS Food Hygiene courses to patients within the State Hospital 2.7 Facilitate and support NTLs / SCNs to complete identified modules of the Cleanliness Programme 2.8 Ensure compliance with the education framework for domestic assistants and other training determined by the Housekeeping & Linen Services Manager and Head of Estates and Facilities 16

17 Standard 3: The organisation has effective communication systems in place to enable continuity of care and infection prevention and control throughout the patients journey Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 3.1 Develop and publish an Infection Control Annual Report and Programme of Work 3.2 Continue with the publication of Infection Control bulletins (minimum of 2 per year) 3.3 Prepare and send quarterly reports with interpretation to Infection Control Committee and briefings to the Hospital Board via the Chief Executive Report. 3.4 Infection Control intranet page enhance availability of information and guidance 3.5 Contribute to the recommendations within the Sexual Health and BBV Framework 3.6 Continue to monitor the HAIRT and subsequently present to the Infection Control Committee and Senior Management Team 17

18 Standard 4: The organisation has a surveillance system to ensure a rapid response to HAI Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 4.1 Weekly Norovirus and Influenza Activity (seasonal) reporting to Health Protection Scotland and review of National Data. 4.2 Maintain surveillance of alert organisms such as HIV, HBV, and HCV. 4.3 Continue to review all Infection Control related DATIX and escalate where appropriate Standard 5: The organisation demonstrate effective antimicrobial stewardship Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 5.1 Undertake biennial audit of Antimicrobial use. 5.2 All registered nurses will undertake the NES Antimicrobial Workbook 18

19 Standard 6: The organisation demonstrates implementation of evidenced based infection prevention and control measures Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 6.1 Ensure access to National Infection Control Manual is available on intranet 6.2 All IPC polices are reviewed within a 2 year time frame 6.3 Review HACCP manual for the main kitchen 6.4 Review the Food Safety Manual for the Therapeutic Kitchen in line with Food Hygiene Regulations / Standards 6.5 Develop an Infection Control Audit Programme 6.6 Collate audit results and feedback to key stakeholders 6.7 Complete Self Assessment as directed by Health Improvement Scotland (HIS) 6.8 Ensure all recommendations and requirements from the HEI reports are addressed 6.9 Continue to support ward based staff to undertake Hand Hygiene audits monthly and action shortfalls Review operational Pandemic Influenza Plan for the State Hospital and present to the Resilience Group 19

20 Standard 7: Systems and processes are in place to ensure the safe and effective use of invasive devices Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 7.1 Ensure national catheter associated urinary tract infection (CAUTI) bundles are utilised 7.2 Investigate any infection pertaining to an invasive device & report to the Infection Control Committee and Patient Safety Group Standard 8: The environment and equipment (including reusable medical devices) used are clean, maintained and safe for use. Infection risks associated with the built environment are minimised Aims for delivery 2017/18 Progress to date Review Issues / Challenges / Actions Planned 8.1 Review cleaning schedules and risk assessments in line with the NHSScotland NCSS 8.2 Ensure compliance with NCSS 8.3 Ensure that the monthly domestic monitoring tool is sign off and feedback is provided to SCNs 8.4 Continue with the annual peer and public reviews 8.5 Continue with monthly meetings between APIC and Housekeeping and Linen Services Manager to share information and discuss 20

21 pertinent issues. 8.6 Establish bimonthly meetings between ICM, APIC, Housekeeping & Linen Services Manager and the Estates & Facilities Manager as per HDL (2005) 8 and HDL (2001) Review the decontamination SLA between Falkirk Sterilising Unit and the State Hospital 8.8 Implement HAI SCRIBE and SHFN 30 for any new build or renovation within the Hospital 8.9 Continue to ensure compliance with SHTM Legionella / Water 21

22 INFECTION CONTROL AUDIT PROGRAMME Appendix 2 AUDIT SOURCE AUDIT TOOL USED AGREED FREQUENCY PERSON RESPONSIBLE Comments Respiratory Hygiene and Cough Etiquette * National Infection Control Manual SICPs Audit. SICPs Tool As directed by ICC. APIC Observe 3 staff members in each clinical area Management of Care Equipment National Infection Control Manual - SICPs Audit. SICPs Tool Cleanliness Monitoring HFS and SGHD HFS Audit Tool Hand Hygiene Personal Protective Equipment (PPE) Management of Blood and Body Fluid Spillages NHS HIS HAI Standards (2015), National Hand Hygiene Campaign. SGHD National Infection Control Manual - SICPs Audit. National Infection Control Manual - SICPs Audit. TSH Audit Tool As patient needs dictate. Monthly 2017/18 10 x opportunities Monthly audits per hub throughout 2017/18 APIC Monthly: Housekeeping Annual: APIC Monthly: Ward / Skye Centre Staff Inspect 2 pieces of patient equipment in each clinical area As directed by National Monitoring Tool 4 Hubs, Health Centre and Skye Centre. Annual: APIC SICPs Tool August 2017 APIC 36 observations throughout the Hubs and Skye Centre. SICPs Tool August 2017 APIC Ask 10 members of staff throughout the Hubs and Skye Centre. Mattress Audit MHRA Medical Device Alert Mattresses and MDA/2010/002 TSH Audit Tool February & March 2018 APIC and Housekeeping & Linen Services Manager All mattresses across site Healthcare Waste Audit (incorporating Safe Management of Linen and Safe Disposal of Waste) Workplace Inspection (incorporating environmental audit NHS HIS HAI Standards (2015) and National Infection Control Manual - SICPs Audit NHS HIS HAI Standards (2015) and National Infection Control Manual - SICPs Audit econtrol Book Tool econtrol Book Tool Quarterly Quarterly Quarterly: Control Book Holder Annual: APIC Quarterly: Control Book Holder Annual: APIC Each ward, Health Centre, Sports & Fitness and Occ Health All patient areas across the site over a 24 month period 22

23 Audit of main kitchen against HACCP manual Food Safety Manual Therapeutic Kitchen / Skye Centre Occupational Exposure Management Food Safety Act Food Safety Act SGHD National Infection Control Manual - SICPs Audit TSH Audit Tool TSH Audit Tool August 2017 December 2017 APIC and Catering Manager APIC, Catering Manager and Occupational Therapist Carry out a visual inspection main kitchen and review the HACCP manual Carry out a visual inspection of 2 therapeutic kitchens & review the Food Safety Manual SICPs Tool February 2018 APIC Ask 5 staff members throughout Hubs and Skye Centre Antimicrobial Usage Audit ScotMARAP 2008 TSH Audit Tool July 2018 HEI and HAI Self SGHD and HIS National Tool As per external Assessment updates direction Clinical Effectiveness Clinical Effectiveness and APIC *As required when clinical activity dictates 23