NHS Tayside. Directorate. Infection Control and Management. Annual Report 2010/11

Transcription

1 NHS Tayside Directorate of Infection Control and Management Annual Report 2010/11 Approval Record Date approved Signature Executive Management Team NHS Tayside Board Risk Health and Safety Management Committee (Operational)

2 CONTENTS Page 1. Executive Summary Purpose of this Report 4 3. Governance 4 4. Funding for Infection Control 4 5. Infection Control Work Programme: Hand Hygiene Antimicrobial Prescribing Needlestick Injuries MRSA Screening Staph aureus Bacteraemias New Acquisitions of MRSA New Acquisitions of Clostridium difficile Central Venous Catheter Bacteraemias Surveillance-Surgical Site Infection Alert Organisms Ventilator Associated Pneumonia (VAP) Education and Training Cleanliness Champions Summary Audit Environmental Audits, Sharps Audits, Commode Audits and Snapshots 5.15 Legionella ontamination Communication/Public Involvement Outbreaks/Incidents Summary Inspections and Audits Infection Control Policy and Procedures Complaints 25 Annual Work Programme Outcomes Glossary 31 Linked Documents 31 Infection Control Annual Report

3 1. Executive Summary The Infection Control Annual Report highlights and summarises progress and achievement throughout 2010/2011against the broader HAI agenda and the Infection Control Annual Work Programme. The Scottish Government have again demonstrated commitment to tackling healthcare associated infections by announcing funding for a further year for the Infection Control Manager, Hand Hygiene Co-ordinator and antimicrobial pharmacist until ch NHS Tayside Board approved the establishment of a Directorate of Infection Control and Management in il This establishment allows NHS Tayside (NHST) to have assurance that prevention, management and diagnosis of infection, risk assessment, safety, antimicrobial stewardship, cleaning, facilities and hand hygiene are integrated to ensure a cohesive approach from Board to Point of Care. There has been a concerted effort to meet the HEAT target 2011 to reduce the incidents of all Staphylococcus aureus bacteraemia (including MRSA) by a further 15% by ch NHST in common with other Boards made significant reductions but did not achieve the target. This remains a challenge as 30% of cases are present on admission. Following support from the SGHD, a short life SAB working group was established in ember, 2010 to bring together clinicians, Infection Control & members of the Safety Governance and Risk Team to determine improvement strategies which include working with specific specialties and targeted interventions e.g. PVC insertion and blood cultures. As part of the SGHD programme, all NHS Boards have introduced targeted screening for MRSA since January 2010 for acute hospital admissions. Following a series of special studies during 2010/2011, the screening protocol is to be revised and as from il 2011 will involve a Clinical Risk Assessment to be undertaken. Achieving improvement in hand hygiene compliance continues to be a key priority at a national and local level. All healthcare staff, including medical staff have been challenged to continue to improve compliance and rates have averaged 91% in 2010/2011. The Public Partners HAI Forum, formerly the Public Partnership Group HAI Forum has continued to meet and played a significant role in supporting the work of the Infection Control team including involvement in the Healthcare Environment Inspection of Perth Royal Infirmary in 2010 and Ninewells Hospital in ember Infection control education of staff remains a priority to influence culture and practice. The completion of the Cleanliness Champions programme has continued to increase with 378 having completed during 2010/ This includes 135 members of medical staff. Due to variable attendance at infection control training events a flexible approach has been taken to delivering education in a variety of settings to improve engagement with clinical staff. Work to achieve Glennie compliance in primary care progressed with Broxden Dental Centre opening in ember This has improved decontamination practice in community dental and podiatry services. The majority of General Dental Practitioners Infection Control Annual Report

4 have taken steps to alter their premises to ensure compliance and have implemented recommended processes. This work has been undertaken with ICT support being provided to the NHS Tayside Dental Advisor and local GDPs. 2. PURPOSE OF THE REPORT The purpose of the report is to highlight and summarise progress and achievement throughout 2010/2011 against the broader HAI agenda and the Infection Control Annual Work Programme. 3. GOVERNANCE Reporting and governance arrangements are clearly detailed within the Directorate of Infection Control and Management Committee Aims and Arrangements Document which can be accessed via the Infection Control section of Staffnet. The Waiting Times and Infection Control Accountability Group meets monthly. Each CHP and Directorate is represented and required to submit a written pro-forma prior to each meeting detailing performance. 4. FUNDING FOR INFECTION CONTROL In Financial year 2010/11 Infection Control incurred overall expenditure of 2,320, This allowed clinical and infection control teams to support infection control targets such as surveillance and hand hygiene. Included within this expenditure are the following:- - 1,262k on requirements following Environmental Audits. - Staff costs. - Miscellaneous supplies costs. 5. INFECTION CONTROL WORK PROGRAMME The Infection Control Teams (ICT) are based at PRI, Stracathro, and Ninewells. The teams deliver an integrated service across NHS Tayside. To ensure HAI is prioritised and addressed the directorates and CHPs are monitored via a balanced scorecard on their performance in addressing HAI issues in key areas. The Corporate HAI risk on the SMART system is reviewed twice yearly as a minimum. 5.1 Hand Hygiene The Local Health Board Co-ordinator has continued to develop and implement actions to raise Hand Hygiene (HH) compliance across NHS Tayside. Hand Hygiene auditing continues to be linked with the Scottish Patient Safety Programme. This has been in accordance with the Scottish Government s Zero Tolerance expectations stated in NHS Tayside s response to these expectations can be found on staffnet, please click here to access. Infection Control Annual Report

5 Key developments in 2010/2011: Continued spread of involvement among GP Practices in undertaking a short HH educational package in Perth & Kinross and also in Angus. Community Dental facilities have introduced HH auditing Work at Dundee Dental Hospital to explore the application of the WHO 5 Moments for HH Masterclass events provided across Tayside for various staff groups with skin care education/advice being given a high profile HH Co-ordinator took part in a potential nursing student event at Dundee University HH Co-ordinator has forged links with the Practice Education Facilitator for Care Homes. Training to be planned for those homes where nursing students attend placements Presentation delivered to HNC students at Perth College by HH Co-ordinator Joint event with Dundee University and the PPG as part of the Dundee Science Festival Training provided for Perth & Kinross Council staff in Home Care and Building Services HH Co-ordinator participated in the Public Partnership Group s (PPG) Infection Control Communication Event Introduction of a HH unit, providing non-alcohol based solution, at the Level 5 Dining Room in NW HH Co-ordinator attended the Youth Bus in Arbroath provides healthcare drop in sessions for secondary pupils HH Steering Group reformed with representation from across the Acute and Primary Care sector Ancillary staff supervisors have tested a monitoring form re HH and skin care knowledge National HH audits continued bimonthly during 2010/11 with NHS Tayside sustaining compliance around 91%. The areas audited were stipulated by Health Protection Scotland (HPS), with the actual wards being selected at random locally. NHS Tayside s confidence in their HH compliance continues to be supported locally by clinical staff undertaking monthly audits reported to both Infection Control and the Scottish Patient Safety Programme. This includes all hospital settings, including the Integrated Dental Service. Infection Control Nurses also support the overall auditing process through their annual snapshot process. The number of clinical areas reporting their HH compliance has continued to increase: 11 areas in ember areas in ember areas in ember Antimicrobial Prescribing The Antimicrobial Management Group Annual Report for 2010/11 will be added to this report when available, completion anticipated end of Infection Control Annual Report

6 5.3 Needlestick injuries Various safety devices have been introduced with training and education provided, however, the number of needlestick injuries continues to be of concern. A short life Sharps Group has been established to review sharps management. 5.4 MRSA Screening As part of the SGHD programme, all NHS Boards have introduced targeted screening for MRSA since January 2010 for acute hospital admissions. The target group was all elective admissions with an overnight stay and emergency admissions to nephrology, care of the elderly, dermatology and vascular surgery wards. Following a series of special studies during 2010/2011, the screening protocol is to be revised and as from il 2011 will involve a Clinical Risk Assessment to be undertaken to identify those requiring to be screened as well as continuing with screening for all admissions to the specialties of Orthopaedic, Renal, vascular and cardio vascular. 5.5 Staphylococcus aureus Bacteraemias (SABs) NHS Tayside narrowly missed the target 2010 target number by 10 episodes and did not achieve the target to the end of ch 2011, though the trend over the years has been downwards. The major reduction was seen in the MRSA episodes % of the overall numbers of episodes are related to community acquisition and are thus difficult to prevent. IVDUs account for a significant proportion of community acquired episode and work has been started with the Harm Reduction Team. Ninewells and PRI figures are shown below. A SAB action group was set up ember and the Board participated in a 90 day improvement plan. New skin disinfectant was introduced for taking blood cultures and insertion of intravascular cannulae such as central, peripheral and arterial lines. 25 c-chart for Number of MRSA and MSSA Bacteraemias taken in Ninewells Hospital (including those taken within 48hrs of admission) Jan No. of Bacteraemias No. of Bacteraemias Mean UCL LCL 0 UWL Jan-08 LWL Jan-09 Jan-10 Jan-11 6 per. Mov. Avg. (No. of Bacteraemias) Month NB: Mean and Limits recalculated at 2009 Infection Control Annual Report

7 9 c-chart for Number of MRSA and MSSA Bacteraemias taken in Perth Royal Infirmary (including those taken within 48hrs of admission) Jan No. of Bacteraemias No. of Bacteraemias Mean 0 UCL UWL Jan-08 Jan-09 Jan-10 Jan-11 6 per. Mov. Avg. (No. of Bacteraemias) Month 210 Number of S. aureus Bacteraemias in NHS Tayside Annual Rolling Total in Line with HEAT Target Number of S. aureus Bacteraemias No. S. aureus Bacteraemias HEAT Target Figure 1 Jan-09 Jan-10 Month Jan Number of S. aureus Bacteraemias per Group (Ninewells and PRI) il 2009/10 and il 2010/ Number 30 MSSA MRSA / / / / / / / / / / / /11 Medical (N1-6,P3,P6) Surgical (N7-12/HDU,P1,P5) Orthopaedics (N16-19,P7-8) Renal (N22/RDU,PRDU) Ward N20/PITU Admissions (N15,NAE,P4) Group Infection Control Annual Report

8 5.6 New Acquisitions of MRSA All sites continued to make good progress with a general trend to a reduced number of new MRSA acquisitions. This has almost certainly impacted on the SABs Screening of overnight electives cases and all admission to dermatology, vascular, renal and acute care of elderly was implemented as per National requirements. Figure c-chart for Number of New MRSA Acquired in Ninewells Hospital Jan No. of New MRSA Mean UCL LCL UWL LWL 6 per. Mov. Avg. (No. of New MRSA) No. of New MRSA Jan-08 Jan-09 Jan-10 Jan-11 Figure 3 16 Month c-chart for Number of New MRSA Acquired in Perth Royal Infirmary Jan NB: Mean and Limits recalculated at 2009 No. of New MRSA Mean 14 UCL LCL UWL 12 LWL 6 per. Mov. Avg. (No. of New MRSA) No. of New MRSA Jan-08 Jan-09 Jan-10 Jan-11 Month NB: Mean and Limits recalculated at 2010 Infection Control Annual Report

9 Figure c-chart for Number of New MRSA Acquired in Royal Victoria Hospital Jan No. of New MRSA Mean UCL UWL 6 per. Mov. Avg. (No. of New MRSA) Jan-08 Jan-09 Jan-10 No. of New MRSA Jan-11 Month NB: Mean and Limits recalculated at ch New Acquisitions Clostridium difficile Local data (which includes all new cases not just the >65 yrs) is showing trend towards reduction (Figs 5-7) in all acute sites and RVH. The HEAT target (figure 8) was met. Outbreaks are detailed in the incidents and outbreaks section. Figure 5 35 c-chart for Number of New Patients with C. Diff Acquired in Ninewells Hospital Jan No. of C. Diff Cases Laboratory Testing Algorithm Changed tember No. of New C. Diff Patients No. of C. Diff Episodes 5 Mean UCL LCL 0 UWL LWL Jan-08 Jan-09 Jan-10 Jan-11 6 per. Mov. Avg. (No. of New C. Diff Patients) Month NB: From Counting only New Patients Mean and Limits recalculated at ober 2009 Infection Control Annual Report

10 Figure c-chart for Number of New Patients with C. Diff Acquired in Perth Royal Infirmary Jan Laboratory Testing Algorithm Changed tember 2009 No. of New C. Diff Patients No. of C. Diff Episodes Mean UCL UWL 6 per. Mov. Avg. (No. of New C. Diff Patients) Jan-08 Jan-09 Jan-10 No. of C. Diff Cases Jan-11 Figure Month NB: From Counting only New Patients c-chart for Number of New Patients with C. Diff Acquired in Royal Victoria Hospital Jan No. of New C. Diff Patients No. of C. Diff Episodes Mean UCL 8 7 UWL 6 per. Mov. Avg. (No. of New C. Diff Patients) No. of C. Diff Cases tember 2009 Cipro Removed Laboratory Testing Algorithm Changed Jan-08 Figure Jan-09 Month Jan-10 Jan-11 NB: From Counting only New Patients Mean and Limits recalculated at y 2009 Number of C. Diff Cases/1000 AOBD in NHS Tayside (NOT all Hospital Acquired) for Patients > 65 years Annual Rolling Total in Line with HEAT Target Rate/1000 AOBD Rolling total HEAT Target Jan-09 Jan-10 Month Jan-11 NB: Updated AOBD for 2009 received Infection Control Annual Report

11 5.8 Central Venous Catheter (CVCs) Bacteraemias 7 CVC Infection Rate/1000 Catheter Days for Ward 20, Ninewells Hospital Jan Rate/1000 Catheter Days Jan-10 Jan-11 Month 2 CVC Infection Rate/1000 Catheter Days for Ward 22, Ninewells Hospital Jan Rate/1000 Catheter Days Jan-10 Jan-11 Month The Renal Unit continues to experience CVC related infections in these vulnerable groups with numerous risk factors and actions as per staphylococcal bacteraemia are being undertaken. Regular screening for staphylococcal carriage continues in the renal patients. Infection Control Annual Report

12 600 CVC Infection Rate/1000 Catheter Days for Wards 7-12 including SHDU, Ninewells Hospital January ch No. of Catheter Days CVC Treatment Plan & Safety Bundle 500 Commenced in Ward 10/SHDU & Use of ChloraPrep Applicators & Clinell Wipes 200 Commenced CVC Line Care & Bundle Education Sessions carried out CVC Line Insertion Trolley's Purchased for SHDU & Ward 11 - All Wards (including SHDU) Commenced CVC Care Bundle - 3 Day Surveillance Period Finished 04/10/09 New Data Collection System Introduced ~21/09/ Rate/1000 CD Total CD Rate/1000 CD Target Line for Rate/1000 CD 6 per. Mov. Avg. (Rate/1000 CD ) Jan Jan Jan Month 5.9 Surveillance Surgical Site Infection PRI and Ninewells operates a proactive 30-day telephone post discharge surveillance (PDS) for all primary total hip and knee joint replacements and Caesarean sections procedure. Mandatory 30 day PDS is occurring for all other hip procedures including fracture neck of femur, hip revisions and resurfacings, continues through passive surveillance. Ninewells also continues with 30-day telephone PDS in Caesarean-section and abdominal hysterectomy surgery. Certain vascular procedures are subject for surveillance also. The results of surveillance are fed back to Directorates as SPC charts. Superficial and deep Surgical Site infection Report NHS Tayside Jan (latest data set available as there is a 30 day post operation surveillance period) Operations Infection rate (%) Local targets (%) Breast C section Neck of femur Hip replacement Knee replacement Abdominal hysterectomy (TAH) Major vascular surgery The SSI programme continues to identify any deviations and allow investigations to be done where required. Individual months may demonstrate high SSI rates which Infection Control Annual Report

13 should be treated with caution when the number of operative procedures is low, small numbers are annotated on the statistical process control charts when a significant deviation occurs. When a trigger of 2 SSIs is identified within 30 days of a specific procedure, Infection control is notified. Deviations are reviewed to identify any issues, evaluate practices and recommend relevant actions. HPS identified that the cumulative incidence of inpatient or PDS SSI to day 10 for C section procedures between 1 st y to 30 th tember were higher than expected. NHS Tayside was above the 95% confidence limits with a rate of 5.4% (14 superficial SSIs from 261 procedures). A review was carried out and several areas identified for action including : Standardisation of theatre practice in relation to skin disinfection Introduction of Chlorhexidine 2% in 70% alcohol for skin preparation. Use of warming pads Environmental audit of theatre environment Change in antibiotic prophylaxis dosing to within 30 minutes of incision rather than after cord clamping An action plan was returned to HPS in response to the quarterly exception report which included the above actions. The rate returned to baseline before the interventions but these were all deemed to be significant improvements to be introduced anyway Alert Organisms The Infection Control Team monitors the incidence of a number of organisms which have characteristics such as antibiotic resistance or the potential to cause outbreaks. These are termed alert organisms. These are reported in Scorecard format and relevant reports to clinical areas as a monitoring tool. Details on breaches can be found in the outbreaks and incidents sections. 20 Number of New ESBL Patients per Month Jan 2009 onwards Number of Patients Angus CHP P & K CHP Dundee CHP STX PRI NW Jan-09 Jan-10 Month Jan-11 Infection Control Annual Report

14 5.11 Ventilator Associated Pneumonia (VAP) 16 VAP Rate/1000 Ventilator Days for Ward 20, Ninewells Hospital Jan VAP/1000 Ventilator Days Jan-10 Jan-11 Month The locally set target is to remain below 15 episodes per 1000 ventilator days in this unit, which accommodates trauma, medical and surgical cases. Ventilator bundles are in place but the rate will be driven but the nature of the patients. It can be seen that this target was attained Education and Training An awareness week was carried out in Tayside in ober The Dundee team involved radio, TV and local media and manned a stand at Ninewells Hospital which covered topics such as hand hygiene, norovirus, flu and other relevant infection control measures that public and staff can undertake to help reduce risk for patients. It also incorporated a poster campaign in relation to norovirus and these posters were displayed in all entrances to clinical premises across NHST. In Angus and Perth & Kinross the same topics were covered with Infection Control awareness information boards placed in different sites. The infection control nurses manned a number of stands with a good response from both staff and public. 59 Perth & Kinross Community staff also attended an interactive Infection Control session including MRSA, PPE and community based practice. KSF has been carried out for all members of the ICT nursing team, 4 members of the Dundee team and 1 member of the Angus team continue to carry out their MSc infection control. 2 members of Angus and Perth & Kinross Team have successfully completed Specialist Practitioner in Infection Prevention and Control and 1 staff member of the Dundee team has carried out a surveillance module with UHI. Summary of Education from il ch 2011 (see over) Infection Control Annual Report

15 Summary of Education from il ch 2011 Summary of documented Education Ninewells, RVH, Ashludie, Carsview, Kingscross, Strathmartine All Activities Staff Groups Numbers Nursing Staff 1023 Untrained Nursing Staff 401 Student Nurses 110 Support Services 357 Porters 29 Medical 44 Medical Student 3 4 th Year Medical Students 131 Radiographers 39 Podiatry 27 Pharmacy 20 Physiotherapists 8 Physiotherapist Students 1 Volunteers 24 Laundry 70 TORT Centre Staff 48 Wallacetown Staff 19 A & C 12 Cleanliness Champions 29 Student Technician 1 Support Workers 3 Occupational Therapists 3 Angus (Stracathro and Community Hospitals) All Activities Staff Groups Numbers Nursing Staff 397 HCA/NA 177 Support Services 127 Medical 2 AHP 100 Cleanliness Champions 41 Perth & Kinross (PRI and Community Hospitals) All Activities Staff Groups Numbers Nursing Staff 608 HCA/NA 285 Support Services 417 Medical 160 AHP 108 Cleanliness Champions Cleanliness Champions 2010/11 continued the trend from the previous year with continued improvement in the number of people completing the Cleanliness Champion programme. The annual Cleanliness Champion update sessions held at Dundee, Perth and Angus were attended by staff from both Primary and Secondary care. The feedback from these sessions was very positive with comments and evaluations received being used to develop the programme for the next year. Infection Control Annual Report

16 Updates were also held for Dental staff and were incorporated into the Clinical Effectiveness days. Session topics were: Hand Hygiene Personal Protection Equipment H1N1 C.difficile/MRSA Update of Infection Control Annual Programme Infection Control Policy/Microbiology updates Skin infections Nursing and Midwifery students from the University of Dundee undertake the programme as undergraduates. There is now a robust system to identify these staff when they take up employment within NHS Tayside and these are added to the database of champions in the organisation. Medical and Dental undergraduates also continue to undertake the programme as an integral part of their undergraduate studies. By the first quarter of 2011 the average number of people completing the programme was 34 per month, an increase from last year. By the end of the year 2010 there was 1646 qualified champions across NHS Tayside and 946 were undertaking the programme Audit The tool that is utilised during an Healthcare Environment Inspection (HEI) process was reviewed to inform the production of a HAI Quality Assurance Monitoring Tool(HAI QAMT) that both the ICT and clinical ward staff are at present trialling. During ember 2010 and January 2011, a series of internal inspections of every ward/department in Ninewells and PRI was undertaken using the revised tool. This audit process was carried out collaboratively with input from Estates, Procurement, Domestic Services, along with clinical and infection control staff. By adopting this approach it is the intention to increase clinical ownership and demonstrate improvement which can be evidenced by the Improvement Action Plans that are regularly updated and shared. Discussions are ongoing to agree an audit process for the ICT which fulfils HAI requirements without duplicating audits already carried out by Estates/Domestic Services. A self-assessment audit tool was produced for GP practices to carry out their own audit with Infection Control staff providing advice on request. This will be monitored as part of the Primary Care contract. The Infection Prevention Society (IPS) introduced a new electronic audit tool in ober 2010 which was reviewed by the ICT. (1) Environmental Audit As from ember 2010 the planned Infection Control audit programme was reduced to take account of the internal inspections as above. Infection Control Annual Report

17 Audits Undertaken - Dundee:- 82 audits in Ninewells - 23 not done 14 audits in GP Surgeries (podiatry/dental) 46 audits in Dundee Community Hospitals - 7 not done Audits Undertaken Angus 9 audits in Stracathro 10 audits in Dental and Podiatry Practices 21 audits in Community Hospitals Audits Undertaken Perth & Kinross 38 audits in Perth Royal Infirmary 6 audits in Dental and Podiatry Practices 22 audits in Perth & Kinross Community Hospitals 9 audits in Perth & Kinross Community Bases NHS Tayside continued to be monitored against the national cleaning specification and consistently scored green (compliance of 90% and above). The cleanliness of our hospitals continues to be a priority for 2010/11. (2) Sharps Audit Daniels, an external company, carried out an audit of sharps bins within all NHST hospital premises. In summary feedback was positive and demonstrated that compliance with sharps handling and disposal was high. There were a small number of containers not labelled whilst in use and staff not using the temporary closure which may predispose to injuries. (3) Commode Audit Angus and Perth & Kinross wards are undertaking commode audits and these have been included in the Infection Control monthly walkabouts (4) Snapshots These observational studies of various healthcare personnel enabled the Infection Control staff to look at general activities and work patterns in a variety of clinical areas over a 1 1½ hour period in order to identify any areas where Infection Control practices could be improved. A small number of snapshots as scheduled in the Infection Control Programme were not able to be completed due to the internal inspections carried out as above. During the Infection Control team carried out 51 snapshots in Ninewells Hospital (5 not carried out) 17 snapshots in Perth Royal Infirmary 4 snapshots in Angus community 5 snapshots in Stracathro Hospital 6 snapshots were undertaken in Perth & Kinross community 14 in Dundee community (4 not carried out) The majority of snapshots were undertaken once throughout the year in each clinical area, however, some areas were undertaken more than once due to risk assessment. Infection Control Annual Report

18 A hand hygiene audit is undertaken simultaneously using a hand hygiene observation tool. The observation periods constantly identified recurring problems in the majority of areas visited. (text not changed from report) The most common problems identified were: Misuse of PPE Laundry and waste disposal issues Staff wearing wrist watches whilst carrying out hand hygiene or clinical care (mostly medical staff PRI only medical) Soap onto dry hands Taps being turned off by hands (increasing installation of sensor taps will reduce this non compliance) Wearing stoned rings Hand washing taking less than 10 seconds 5 key moments not being adhered to. Key moment 5 being the most common failure 5.15 Legionella The Legionella (and latterly Water Quality) Group has met approximately 5 times over the year.. The group was set up to oversee surveillance, sampling and response requirements in accordance with current Scottish Health Technical Memorandum (SHTM) 2040 and HSE Approved Code of Practice and Guidance Document (L8). The revised SHTM & (which replaced SHTM 2027 & SHTM 2040) is due for publication early A pan Tayside policy has now been implemented and has been approved by HAI Team. This will be revised on the publication of the new SHTMs. The current external Water Management consultancy has expired and a tender exercise is currently under-way to appoint a new consultancy. It is hoped to appoint a new term consultancy by end The existing risk assessments of the water systems across NHS Tayside are still extant and recommendations from these are being worked through which includes regular testing for Legionella across the Delivery Unit. There is an ongoing programme of expanding the testing regime across NHS Tayside and numerous smaller sites within the previous primary care umbrella are now part of this regimen. It is hoped that within the next 24 months a robust sampling regimen will cover all properties within NHS Tayside. Currently the sampling regimen is carried out quarterly with notifications of results passed back from the water consultant to the relevant microbiologist as well as the Responsible person and Deputy Responsible persons. These results are also trended over several periods in order that relevant action can be carried out to areas where it appears a common or regular occurrence of higher than normal counts appears. The Logbook system is working well with all work carried out on water systems recorded as a matter of course. These logbooks will be externally audited by our external water consultant to ensure accuracy and governance once Infection Control Annual Report

19 appointed. Investigations are still ongoing to look at the possibility of introducing an electronic logbook in the near future. Showerhead cleaning has been identified as a potential major contributor to Legionella and as such a pan-tayside contract with an external contractor is now in place to clean all shower heads on a quarterly basis. Thermostatic Mixing Valves (TMVs) have also been identified as a potential major contributor to Legionella as well as scalding and as such an external contractor now carries out 6 monthly and annual checking and testing of these at Ninewells Hospital and in-house estates staff carry out the same function elsewhere. Tank cleaning has been carried out locally on each site with the intention being that a pan Tayside contract will be put in place in the near future. All estates staff have been trained in Legionella awareness and investigations are being carried out into the introduction of e-training for clinical groups which would be staffed and managed by the Infection Control Team as part of any other updates ontamination ontamination Compliance in Primary Care A Business case was developed for decontamination compliance in primary care. This relates to general practitioner, podiatry and community dental services. Following an extensive options appraisal exercise further work is being undertaken to support either the development of local decontamination units or centralisation in the Ninewells/Stracathro Central ontamination Units. The new Broxden Dental Centre, LDU will undertake all Perth & Kinross NHS dental and podiatry decontamination. The decontamination solution for Dundee and Angus community dental and podiatry sites will consist of a combination of CDU provision and increased LDU utilisation at Kings Cross. Endoscopy Update 2010/11 NHS Tayside now has two sites providing endoscopy decontamination services from compliant facilities using Wassenburg washers and Labcaire HEPA cabinets. To date, eleven washers have been installed and are now fully operational and following the initial bedding in period for each washer are proving to be very reliable with washer uptimes over 98%. The new PRI endoscopy unit which is due completion at the end of 2011 will complete the final phase of the general endoscopy decontamination service upgrade. ENT nasendoscopy decontamination is currently carried out across NHS Tayside using a manual decontamination process. The manual washing and use of a disinfectant wipe was introduced as an interim solution due to concerns from the clinicians that the previous method of using sheaths obscured their view with the potential for inaccurate diagnosis. NHS Tayside is currently reviewing the various decontamination processes that should facilitate sensible and informed choices on the decontamination of endoscopes based on the actual relative risk of cross infection. Any decision on the way forward will require a balanced consideration of the various factors together with an analysis of the perceived risk, taking cognisance of new UK ENT decontamination guidance recommendations. Infection Control Annual Report

20 Dental As there is currently no validated process for the decontamination of dental handpieces, a risk assessment for handpieces was compiled and agreed with the Dental Hospital and HPS. In addition to further address this issue, a dental handpiece working group (DHWG) has been established by Health Facilities Scotland (HFS), at which the Integrated Dental Service has representation, to clarify decontamination processes and provide a way forward that will support external and internal decontamination using the range of equipment available under the current (and future) National Contract. The National Procurement contract went live on the 1 st of ch with NP issuing contract details to all Health Boards. Most of the dental handpieces in the contract do not have adequate manufacturer s instructions, but by signing the contract the manufacturers/suppliers have agreed to work with the DHWG. A meeting is to be arranged with the manufacturers in the hope that they can be influenced to improve their decontamination instructions. 6. Communication/ Public Involvement The Public Partners HAI Forum met 5 times during 2010/11. A communications event was held in 2010 to promote wider engagement with the members of the Public Partners not routinely involved in HAI activities. The event was chaired by the General Manager Infection Control & Management and had representation from public partners, clinical and infection control staff. The event was received positively by all, with particular benefit gained from the workshops allowing greater understanding of both clinical and public viewpoints. It is proposed to have a similar event in During this reporting period Public Partners have been involved in: Hand Hygiene Science Event with Dundee University. Review of patient information leaflets and HAI Booklet Involvement in HEI Inspections Participation in Infection Control & Management Committee Participation in Cleaning Monitoring 7. INCIDENTS/OUTBREAKS Summary Table (see over) Infection Control Annual Report

21 7. INCIDENTS/OUTBREAKS Summary Table DATE AREA TYPE ACTIONS ch-il Ward 22 NW Clostridium difficile Outbreak team formed. Ward (CDI) - 12 patients did not require to be closed affected with 4 different due to time separation of strain types over a 4 cases. month period. Terminal clean implemented and continues to date on a 3 monthly basis Lack of single room isolation facilities highlighted as a risk for this ward Options to rectify this currently being evaluated. Importance of strain typing highlighted in terms of outbreak declaration Ward 8 NW Tay Ward, PRI Various CDI - 4 patients affected with 3 different strains CDI 4 patients affected over a 6 week period. Chickenpox admitted for emergency treatment during asymptomatic but infectious stage of disease Ward did not require to be closed. Variety of strains suggest imported into ward rather than spread within ward. Demonstrated working of ALERT system. Outbreak team formed and assessed as Red risk. Ward was closed for 9 days followed by a period of ward refurbishment. All Infection Control precautions were adhered to and no further cases were identified. Terminal clean was undertaken. Staff and patient contact tracing for those not known to have previously had chickenpox. Some staff still unaware of VZV status prior to exposure despite this being part of checks and education Infection Control Annual Report

22 DATE AREA TYPE ACTIONS -e Ward 11 NW Maty/NICU Medical 9 patients diarrhoea presumed viral but all laboratory tests were negative for viruses and bacteria. MRSA increase in community acquired cases of MRSA (7 babies or mothers) detected over 8 week period. Of these 3 were identified as MRSA PVL producers of the same type. Others were different types and unrelated to each and deemed community acquired. Rubella tember NW Maty Special cause variation in surgical site infection for C sections (5.4% which was above the 95 th centile) in the 2nd quarter 2010 ember Montrose Infirmary Legionella in 4/6 routine surveillance samples Ward closed for 2 days and terminal clean given. Problem assessment group met several times. Infections were superficial if present. Some changes to practice introduced. Unit was not closed. MRSA admission, weekly and discharge screening introduced and no further cases detected since y Was not in single room in one of the medical wards despite the rash which could have been infectious before lab tests were back. However there were no exposures for female patients or pregnant staff. Case highlighted need for awareness of single room use for patients with undiagnosed but potentially infectious rash Problem assessment group convened. No common factor identified and returned to baseline without any intervention. Several areas for improvement highlighted such as re-timing of antibiotic prophylaxis, improved patient advice on wound care, warming blankets. There are environmental issues which need to be addressed and these have been highlighted Problem assessment group Thermal disinfection Use of filters on high risk outlets Birthing pool out of use Improvements to waterlines Re-test was clear No clinical cases Infection Control Annual Report

23 DATE AREA TYPE ACTIONS ember NICU MSSA- PVL in 3 babies of same strain. ruary to date Norovirus Various mainly surgical 25 wards affected on different occasions across NHST MSSA ETA producer in 5 infants all of same strain Vancomycin resistant enterococci. Increase in clinical isolates of VRE noted over end of year in surgical wards 289 patients with suspected or confirmed norovirus (330 including il and 2010) Superficial infections identified by unusual antibiogram. All actions in place following MRSA PVL. No further cases detected but source not identified. Superficial infection except one infant with a moderately severe skin infection. Strains identified in 2 cases because of atypical behaviour on MRSA screening plates and heightened awareness in terms of PVL staphylococcal history in the unit. Complex outbreak with VRE. Outbreak team convened and managed as Amber. Active surveillance introduced which finds as expected increased cases. Surveillance positives far exceed clinical isolates at point of writing. Several strategies pursued in different areas depending on risk assessment. Numbers of patients overall were slightly down for this season compared to last ( to il). 1 st episode was in late ember and season lasted until end of ch into il of The peak month was ch staff affected in the affected wards (98 including il and 2010) The peak number affected per month was broadly comparable this year and last year, but occurred a month later. Medical unit at NW saw the bulk of the cases this season accounting for just over half of the total NHST cases. Wards were shut for a total of 185 days for the ember 2010 season Infection Control Annual Report

24 8. INSPECTIONS AND AUDITS 8.1 External Audits/Inspections The Healthcare Environment Inspectorate (HEI) are now in year 2 of their programme which includes both announced and unannounced inspections to acute hospitals. PRI had a favourable announced inspection in 2009 with Ninewells Hospital having an unannounced inspection in ember 2010 resulting in 11 requirements and 4 recommendations. NHS Tayside submitted a revised on-line HAI Self Assessment in ruary The Infection Control Team invited review from Health Protection Scotland (HPS) relating to a C difficile Outbreak in the Renal Unit in il 2010 and VRE within the Surgical Directorate during winter Internal Inspections/Audit: Inspections which focussed on HAI and Health & Safety (H&S) were carried out as listed:- Domestic Service Facilities at Dundee Dental Hospital Catering Department Changing Rooms at Ninewells Hospital Sharps Awareness Audit (Daniels) Endoscopy, Ninewells Hospital Commode Audit (Vernacare) The focus of inspections was to highlight good practice and make suggestions where improvements could be made. Verbal feedback was provided to local managers on the day and a written report followed which was prepared by OHSAS with ICT input. Examples of some of the key findings were: Lack of storage facilities resulting in inappropriate placement. Fabric issues such as general maintenance of environment e.g. flooring, plasterwork, etc. Overfilling and inappropriate items within sharps bins. Two audits were undertaken by the NHS Tayside Internal Audit Service:- T35-10 Purchasing The audit reviewed the systems, procedures and controls within NHS Tayside for ordering, requisitioning and receipt of goods from external suppliers. This included a review of the processes in place for ordering goods through the National Distribution Centre (NDC). The audit findings rated the processes as Category C Adequate, in that the system has weaknesses that do not threaten the achievement of control objectives. The audit recommendations are being addressed. T26-11 HAI Cleaning Infection Control Infection Control Annual Report

25 The audit carried out a review of the cleaning services across a sample of NHS Tayside sites. The audit was based at Stracathro and Murray Royal Hospital. The audit findings rated the processes as Category B broadly satisfactory, in that the system meets control objectives with minor weaknesses. 9. INFECTION CONTROL POLICY AND PROCEDURES The Infection Control Policy is available on the Safe & Effective Working Section of Staffnet and is updated regularly to reflect developments and changes to current practice. As the policy is a large document, individual sections of the policy have been hyperlinked to and to improve ease of access and aid navigation. Paper copies are regarded as uncontrolled if printed. 10. COMPLAINTS There were 6 complaints reported to Infection Control for Tayside between the months of il 2009 until ch for Ninewells, 2 for PRI. The complaints were received from patients/relatives/visitors. Every complaint was treated individually and full detailed explanations were given back to the complaints office. In summary the complaints were related to the following: Poor standards of environmental cleanliness. Nursing and medical care in relation to hand hygiene compliance MSSA and Clostridium difficile General complaint in relation to HAI. Appropriate action was taken by the Infection Control Team liaising with all appropriate services. Infection Control Annual Report

26 Infection Control and Management Directorate - Annual Work Programme 2010/11 Part Two: Specific Activities / Developments Objective Action Required Timescales 1. GOVERNANCE Implement ICMD HAI Driver Diagrams and Directorate Structure Actions plans for external and internal reviews All levels to implement as per HAI Driver Diagrams Monitor progress with external and internal audit reports e.g. HEI, internal audit, SGHD template report, HFS visits 2. PREVENTION AND CONTROL OF INFECTION i.) HAI Strategy Ensure HAI is prioritised and addressed in clinical and non-clinical areas ii.) Hand Hygiene Improve hand hygiene practice and compliance to 95% of opportunities taken in all areas iii.) Skin Health iv.) Antimicrobial Prescribing Work with JCBs and CHPs to embed HAI learning and pro-active action. Review corporate HAI risks identified on SMART system 2010/11 Hand Hygiene Action Plan Develop and implement hand care policy. Increase assurance around antimicrobial prescribing in line with policy. Utilise available resource to support clinical staff to maximise benefit to patients End of ch 2011 End of ch 2011 e 2010 ember 2010 At each ICM committee ember 2010 Responsible person As per HAI Driver Diagrams Performance Indicator/ Outcome Progress Completed All responsibilities are discharged as per HAI Driver Diagrams HAI Extract from JCBs/CHPs to be provided for each ICMC. Reissued to GMs, AMDs and ADNs GM ICM HEI Action Plans updated y, ember 2010 and January and ch GM ICM/ GMs Clinical team ownership. Performance monitored via a number of forums GM ICM / RM Reviewed 6 monthly. e, 2010 and ruary 2011 review completed. HHCOD / GMs / CHP Managers DICM Progress monitored by Infection Control and Management Committee Better Skin Health for staff. Links to H&S re surveillance e 2010 IC SMT Completed audits as per AMG requirement End of ch 2011 ICT/LPAP/NC HAI Improved antimicrobial prescribing Complete for 2010/11 Continuing forward for 2011/12 Guidance issued ch Ongoing audits done monthly, policy distributed ust Complete for 2010/11. Continued forward for 2011/12. Complete for 2010/11 Continuing forward for 2011/12 Infection Control Annual Report

27 2. PREVENTION AND CONTROL OF INFECTION (ctd.) Further implementation of antibiotic review bundle with measurement of impact. v.) Reduce intravascular device associated infections vi.) Review CAUTI Surveillance vii.) MRSA screening viii.) OHSAS Infection Control and Management Directorate - Annual Work Programme 2010/11 Part Two: Specific Activities / Developments Further engagement with local SPSP leads to integrate surgical prophylaxis SAPG measures into the surgical check list. Input data to HAI Balanced Scorecards for all areas Include antimicrobial prescribing in community pharmacist input to nursing homes through locally enhanced services (LES) iiip methodology to support PIVC and CVC bundles and review of practice and skills in line infections Review Audit MRSA screening compliance with National Programme Audit MRSA decolonisation scripts as prescribed by ICNs (10 samples per annum) Immunisation screens complete End of ch 2011 End of ch 2011 End of ch 2011 End of ch 2011 LPAP LPAP LPAP/DICM LPAP Audit as required. Improved antimicrobial prescribing Improved antimicrobial prescribing. Monthly data on quality of prescribing discussed for all areas. Improved knowledge of antimicrobials for community pharmacists and nursing home staff 2011 NC HAI Reduced line related sepsis as contributory factor in SABs tember 2010 Monthly Annually tember 2010 Complete for 2010/11 Continuing forward for 2011/12 Complete for 2010/11 Continuing forward for 2011/12 Complete for 2010/11 Continuing forward for 2011/12 Initial meeting with LES steering group arranged for il 09. Remit AMG. Now being progressed nationally removed from local programme for 2011/12 External support being provided. NHST SAB short life working group established. NC HAI Unable to progress until national guidance agreed. ICN SNsIC Audit of compliance of 5 patients on a rolling basis In line with policy 100% Results discussed at IC SMT. New protocol as from il No longer appropriate removed from AWP. Infection Control Annual Report Work continuing through 2011/12 OHSAS/HR System secure Complete.

28 2. PREVENTION AND CONTROL OF INFECTION (ctd.) ix.) Reduce SSI, PIVC, Review role of alternative contaminated skin preparation agents blood cultures (e.g. Chloraprep) 3. EDUCATION i.) ii.) iii.) Infection Control and Management Directorate - Annual Work Programme 2010/11 Part Two: Specific Activities / Developments Review HAI Training & Development Strategy 4. ENVIRONMENT AND EQUIPMENT Environmental audits Ensure optimum environment to minimise risk of infection Implement knowledge and skills HAI framework for Nursing and Admin staff HAI update objectives for all other staff as appropriate Introduce an electronic environmental SDU tool Audit compliance with the Estates infection control policy and use of SCRIBE SCNs to complete environmental audits Review IC visits of GMP 2011 DICM Review and costing of existing v new products ember 2010 Review carried out for all CVC/PICC/Aline/ PIVC insertions and skin prep before blood culture and C2A products introduced. Surgical Site preparation only 1 supplier c/fwd into 2011/12 work programme HWK&S/NC HAI Strategy revised & out for consultation, due for launch ch Complete for PIVC and blood cultures Surgical site preparation c/fwd into 2011/12 work programme 2010 NC HAI Complete ch 2011 Education Group Audit x 12 per staff group for assurance per year ch 2011 SNsIC More efficient use of ICN time and reduce paperwork ch 2011 HE 100% compliance as measured by selection of projects per annum Introduction of document ch 2011 ADN First cohort of RTC SCNs using audit tool tember 2011 DICM/ A Cowie Agree pathway. Self Assessment Tool developed. To be included within Health & Safety dimension of KSF. Delayed due to technical issues outwith local team control. Complete tember 2010 Completed by ICNs for 2009/10. Completed for 2010/11. Tabled at GP Sub Cttee Now being implemented within GP Practices. Infection Control Annual Report C/fwd to 2011/12