The Board is asked to: Note the position for the Board. Note the progress to reduce and manage healthcare associated infections.
|
|
- Leo Johnston
- 6 years ago
- Views:
Transcription
1 Highland NHS Board 25 Item 4.5 INFECTION PREVENTION & CONTROL REPORT Report by Catherine Stokoe, Infection Control Manager and Dr Vanda Plecko, Consultant Microbiologist/Infection Control Doctor, on behalf of Heidi, Board Nurse Director & Executive Lead for Infection Control The Board is asked to: Note the position for the Board. Note the progress to reduce and manage healthcare associated infections. Contribution to Highland Quality Approach Strategic Framework and Annual Objectives Contribution to Board Objectives One of the key objectives is to reduce to an absolute minimum the chance of acquiring an infection One of whilst the Board receiving key healthcare objectives and is to ensure reduce our to hospitals an absolute are clean minimum the chance of This acquiring report an presents infection a comprehensive whilst receiving view healthcare of Infection and Control to ensure and Prevention our hospitals data are and clean. activities This report relating presents to annual a comprehensive work plan for scrutiny view of and HAI feedback. data and activities for scrutiny and feedback from the Board. The purpose of this paper is to update Board members of the current status of Healthcare Associated Infections (HAI) and Infection Control measures in NHS Highland. 1. Background and summary The table below shows NHS Highland Infection Prevention and Control targets and performance data. The quarterly data presented below for Clostridium difficile and Staphylococcus aureus NHS Highland is calculated using ember 2013 occupancy data due to unavailability of bed days data for NHS Highland. However NHS Highland bed occupancy will be presented in the tember Healthcare associated infection report published by Health Protection Scotland. Clostridium difficile Staphylococcus aureus bacteraemia Group Target NHS Scotland NHS Highland Age 15 and over HEAT rate of 32.0 cases per 100,000 OBDs to be achieved by year ending 03/17 HEAT rate of 24.0 cases per 100,000 AOBDs to be achieved by year ending 03/ * - 36* 35* 26* Red (HPS validated) Red (HPS validated) Red (HPS validated) Red (HPS validated) Hand Hygiene 95% 97% Green Cleaning 92% 95% Green Estates 95% 97% Green Source: - Health Protection Scotland/ISD/Local data.
2 Our final annual rate position for Staphylococcus aureus bacteraemia cases for / is 30.0 cases per 100,000 occupied bed days, an exceedance of 6.0 cases on the defined HEAT target. For Clostridium difficile Infection our final annual rate position is 32.0 cases per 100,000, occupied bed days is calculated, thus the HEAT target has been achieved. Achievements NHS Highland have met the Clostridium difficile infection HEAT target. The Infection Prevention and Control Nursing Team have assisted Healthcare Improvement Scotland in the development of a new inspection tool and process. Challenges The E-Health teams within NHS Highland and NHS Greater Glasgow & Clyde, and the ICNET (infection control software programme) Project team continue to progress with the automated transfer of microbiological data from NHS Greater Glasgow & Clyde to Argyll and Bute. Expected completion date is 30 th tember. Whilst we await completion of this automated transfer, a reliance on manual data inputting and dissemination of laboratory results may result in errors or delays in infection control information. The Data analyst post appointed on a fixed term contract ended on the 31 st. The loss of this post has resulted in a reduction of a dedicated review of healthcare associated infection cases, and the associated information generated from this post. Currently the Infection Control and Prevention team are exploring ways in which to continue the provision of this posts roles and responsibilities. Work, supported by Service Planning and the Director of Nursing, is underway with E-Health to develop a system for automated data reports. Microbiology Laboratory samples generated by Argyll and Bute are currently all being processed through NHS Greater Glasgow and Clyde laboratories due to local staffing issues in the Oban laboratory. This is a temporary measure and is being closely monitored by the NHS Highland laboratory manager. The reporting of samples from NHS Greater Glasgow and Clyde laboratories to Argyll and Bute is in process via an submission of a daily spreadsheet and follow up phone call. This system is human dependant leading to the possibility of error which is acknowledged on the risk register. Catherine Stokoe Infection Control Manager Vanda Plecko Consultant Microbiologist & Lead Infection Control Doctor,
3 NHS Highland Healthcare Associated Infection Report 1. Staphylococcus aureus (including MRSA) Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at: NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: Staphylococcus aureus bacteraemia target The target for /2018 for NHS Highland is 24 cases or less per 100,000 acute occupied bed days for Staphylococcus aureus bacteraemia (SAB) including MRSA. For NHS Highland this means no more than approximately 60 cases by 31 st Trends NHS Highlands position as of 31 st (data not yet validated by HPS) is tabled below. 1 st MSSA = 7-31 st MRSA = 0 Total SABs = 7 Cases Preventable = 0 Not preventable = 5 Unknown = 1 Under Investigation = 1 Hospital Acquired Cases = 2 (29%) Community Acquired Cases = 4 (57%) Healthcare Associated Cases = 1 (14%) Contaminant = 0 (0%) Undergoing investigation = 0 (0%) Total = 7 For definitions of above classifications please see section 2 page 15 Figure 1: Funnel plot of SAB rates (per AOBDs) for all NHS boards in Scotland in Q1. HG NHS Highland 3
4 Figure 2: NHS Highland Staphylococcus aureus bacteraemia Cumulative Case numbers year on year since The information presented in the graph below is based on NHS Highland case number data. Cumulative Case Numbers NHS Highland staph aureus Bacteraemia- Cumulative chart Aug t Heat Target to All SAB cases undergo a multi-disciplinary team review in order to identify any learning. The action plan developed to implement actions to reduce staphylococcus aureus bacteraemia is in place and monitored through the Infection Control Improvement Group and Control of Infection Committee. 1.3 Current Initiatives A review of practice, performed by the external company Becton Dickinson, on the insertion and management of peripheral vascular devices has occurred. The Infection Control Policy was observed in all but one insertion procedure. Information from this review is currently being shared with the clinical teams. A trial of a pre-filled Saline syringe is underway in NHS Highland. Saline is used to flush through peripheral vascular devices to keep the devices functioning. The use of a prefilled syringe reduces the risk of contamination, needle stick injuries, and releases time to care. 2. Clostridium difficile Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. Information on the national surveillance programme for Clostridium difficile infections can be found at: Clostridium difficile HEAT Target The target for /2018 for NHS Highland is 32 cases or less in patients aged 15 and over per 100,000 total occupied bed days. For NHS Highland this means no more than approximately 78 cases by 31 st 2018.
5 2.2 Trends NHS Highlands position as of 31 st (data not yet validated by HPS) is tabled below. 1st to 31 st Total CDI Cases aged 15 and over = 9 Healthcare Associated = 2 (22%) Community Acquired = 3 (33%) Unknown = 0 (0%) Under investigation = 4 (45%) Aged = 2 Aged 65+ = 7 For definitions of above classifications please see section 2 page 16 Figure 3: Funnel plot of CDI incidence rates (per TOBDs) in patients aged 65 years and above for all NHS boards in Scotland in Q1. NHS Orkney, NHS Shetland and NHS Western Isles overlap. HG NHS Highland Figure 4: Funnel plot of CDI incidence rates (per AOBDs) in patients aged years for all NHS boards in Scotland in Q1. NHS Borders, NHS National Waiting Times Centre, NHS Western Isles and NHS Shetland overlap. HG NHS Highland 5
6 Figure 5: NHS Highland Clostridium difficile Infection Age 15 and over, case numbers year on year since The information presented in the graph below is based on NHS Highland case number data Cumulative Case Numbers NHS Highland Cumulative toxin Positive age 15 and over Aug t Heat Target to Current Initiatives The trial of an Ultra-violet light decontamination machine has occurred within Raigmore Hospital. This technology is proven to reduce the viral and bacterial load of the environment and enhance the effectiveness of manual cleaning. This machine remains in use within Raigmore hospital and is being utilised to support the enhanced decontamination of the environment and equipment. A trial of a similar product from an alternative company is to occur in, as part of the procurement review. The initial trial of the telehealth medicine system Florence has occurred. The aim of Florence is to provide support and advice to patients diagnosed with Clostridium difficile infection through an interactive text messaging system. Further trials are planned, prior to the implementation of the system in the autumn. 2.4 Antimicrobial Management Response to Draft National Guidelines The Antimicrobial Management Team (AMT) provided feedback on the recently circulated Draft Review of Clostridium difficile infection (CDI) Guidance from Health Protection Scotland, mainly in relation to the advice around children and CDI. National Hospital Antimicrobial Prescribing Quality Indicators The detail of these indicators has recently been shared with Antimicrobial Management Teams (AMTs) across Scotland, for achievement by 31 st There are separate indicators for consumption of antibiotics and for review of therapy. The first quality indicator aims to reduce antibiotic use in acute hospitals. Success will be measured as a 1% reduction in total antibiotic use along with a similar reduction in use of specific drugs (carbapenems and piperacillin/tazobactam). Baseline data for each indicator (as quantity of antibiotic per 1000 admissions) has yet to be shared with boards and is not routinely available from the national database, HMUD (hospital medicines utilisation database). The second quality indicator continues to focus on documentation and outcome of review of intravenous antibiotics and documentation of duration of oral antibiotics. This is an
7 expansion of the currently reported audit as data should be collected from at least 3 wards in the main acute hospital. Data for these indicators will be collected using a function on the new NHS Highland Antimicrobial prescribing app. Data to the end of for the current audits in Raigmore ward 7A and 4C show the teams are close to achieving the required standard of 95% already; (ward 7A are at 76% and ward 4C at 78%). Antibiotic Shortages The ongoing national shortage of aztreonam has resolved to some extent but the shortage of piperacillin/tazobactam has commenced with very limited stock available at a vastly inflated price. Clinical teams have implemented the alternative guidance provided and protected stock remains available for severely unwell patients. It is worth noting that the shortage of piperacillin/tazobactam means usage has reduced significantly. Alternative treatment options contain more than one drug therefore total antibiotic use is likely to increase during the measurement period for the national quality prescribing indicators. This has been fed back to the Scottish Antimicrobial Prescribing Group (SAPG). Gentamicin Duration Review A review of how long patients are receiving gentamicin has concluded; results showed that 67% of patients received 3 days or less. A higher incidence of patients having a duration of 4 days was identified on the Surgical wards, and was associated with a restriction in oral intake. The 3 day authorisation code will remain in place in order to prompt a discussion with an infection specialist prior to prescribing. The continuation of gentamicin therapy for longer than 72 hours increases the risk of toxicity and SAPG have recommended that therapy should be reviewed and where possible stopped at 72 hours. The gentamicin prescription form has space for prescribing 3 doses (usually every 24 hours) in an attempt to limit the duration and prompt the review. National Point Prevalence Survey (PPS) report National point prevalence surveys (PPS) are undertaken every five years in Scotland in order to take stock of the current epidemiological situation and to review local and national policy. A rolling point prevalence survey was carried out across all Scottish hospitals in late. Data were collected from a variety of sources by the local Infection Prevention and Control teams and Antimicrobial Pharmacist. The report was published in, and is available to view via the weblink below: Overall the report concludes that the current prevalence of healthcare associated infection (HAI) in acute hospitals within NHS Scotland is 4.6%, and in the non-acute hospitals 3.2% which, whilst significantly lower than five years ago, still represents one in 22 patients at any one time, or 55,500 infections every year. The patient population is notably older and sicker in comparison to five years ago and the most common HAI across NHS Scotland (urinary tract infection and pneumonia) reflects this at risk population. NHS Highland data from the survey identifies our prevalence rate in acute hospitals as 6.0% (26 cases), compared to 4.9% (22 cases) in In the non-acute hospitals a rate of 1.1% (1 case) identified from the survey, compared to 0.7% (1 case) in NHS Highland data does not reflect the national findings for HAI type. The most common cause of HAI recorded across NHS Highland was surgical site infection although a 5.4% decrease on the previous recorded rate was noted (2011 data 36.4%; data 31%) and the second 7
8 most common HAI related to pneumonia ( %; 31%, although it should be noted that actual case numbers are low; 2 in 2011 and 9 in ). Within NHS Highland the median age of patients in both acute and non-acute hospitals was higher in than 2011, (a 7 year increase in acute, and a 22 year increase in non-acute). A larger proportion of patients were also noted to have severe co-morbidities that were expected to be ultimately or rapidly fatal (a 14% increase in data in acute settings, and a 40% increase in data in non-acute). These findings reflect the continuing change in the demographics of the Scottish population. The number of people aged years and 75 years and older in Scotland has increased by 24% and 31%, respectively between 1996 and.the number of people aged 75 years and over is projected to increase by approximately 29% between 2014 and A number of risk factors were associated with the higher prevalence of HAI reported across NHS Scotland in this survey: higher co-morbidity score, having undergone surgery since admission to hospital, being cared for in a surgical specialty and being cared for in a high dependency unit (HDU) or ICU. Patients cared for in surgical specialties or in ICU and HDU are particularly vulnerable to infection due to extrinsic risk factors such as surgical procedures and invasive devices. The use of devices remained largely unchanged across NHS Scotland, although the survey does indicate that a higher number of devices are in use within non acute hospital settings. Within NHS Highland we noted that our use of invasive devices has remained largely unchanged across both settings. The only risk factor reported to be associated with a higher HAI prevalence in the non-acute patients across NHS Scotland was increased age; this reflects NHS Highland data. The report also indicates that across NHS Scotland there has been significant improvement in practice in the prescribing agenda in recent years, although antibiotic prescribing in hospitals was found to be significantly higher than five years ago. Within NHS Highland the prevalence rates of Antimicrobial Prescribing in the acute setting remained the same as in 2011, whilst a slight increase was noted in the non-acute settings likely reflecting the change in patient acuity (2011 data 10.4%; data 16.3%). 3 Hand Hygiene Reporting Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: Each Board is responsible for monitoring and reporting hand hygiene compliance data. 3.1 Current Hand Hygiene Compliance Rates NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas, and compliance rates are being sustained above the 95% target. Compliance data for this year (uary to ) identifies an average of 97% for hand hygiene compliance across NHS Highland. Any areas identified during the audits, as requiring action, are reported immediately to the relevant person for actioning. 4. Cleaning and the Healthcare Environment
9 Keeping the healthcare environment clean is essential to prevent the spread of infections. Information on national cleanliness compliance monitoring can be found at: Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: Each Board is responsible for monitoring and reporting the cleanliness of hospitals. 4.1 Cleaning and Estates audit data The monthly cleaning and estates audits, conducted as per the National Cleaning Services Specification and through the use of Synbiotix (the Facilities Management Scotland web based audit tool), demonstrate compliance rates are being sustained above the locally defined targets (92% domestic monitoring and 95% estates monitoring). The data for this year (uary to ) identifies an average compliance of 95% for domestic monitoring, and 97% for estates across NHS Highland. Any areas identified during the audits, as requiring action are reported immediately to the relevant person A series of unannounced Independent Public Peer Review audits is in progress; these occur across all hospital sites in NHS Highland. Work is underway to implement the revised NHS Scotland National Cleaning Services specification. The revised document allows NHS Boards too accurately and effectively risk assess specific tasks in order to determine the frequency of cleaning, based upon the risk to the patient and also public perception. Progress is reported through the Soft Facilities Management group and monitored through the Infection Control Improvement Group. 4.2 Healthcare Environment Inspections (HEI) The report for the HEI Inspection of Raigmore Hospital theatre department (7 th and 8 th ruary ) was published on the 18 th of, and the subsequent 16 week follow up report has been submitted. This was a very positive visit and the requirements (outlined below) have been met. Requirement 1: NHS Highland must ensure that where audit data suggests compliance with standard infections control precautions is below the accepted standard, action plans are developed, implemented and monitored to support improvement in practice. Requirement 2: NHS Highland must ensure that, where data suggests compliance with standard infection control precautions is below the accepted standard; this information is presented to the Executive team and senior managers in such a way that allows poor compliance to be more visible. This will enable support and continuous improvement in infection prevention and control practice. The report for the HEI Inspection of MacKinnon Memorial Hospital (18 th and 19 th ) was published on the 27 th of. This was a very positive visit and resulted in three requirements, outlined below. An action plan has been submitted, and all requirements have been addressed. Requirement 1: NHS Highland must ensure that audit results are fed back to staff to provide assurance, drive improvement and communicate any risks. Requirement 2: NHS Highland must ensure that the current version of Health Protection Scotland s National Infection Prevention and Control Manual is available to staff. This includes any hard copies of infection prevention and control policies. Requirement 3: NHS Highland must ensure that all waste is disposed of in line with Health Facilities Scotland s Scottish Health Technical Note 3 (2015) and that all staff involved in the management of waste are aware of their responsibilities. 9
10 Benchmarking continues against all the national HEI inspection reports published, in order to ensure learning is disseminated. 5. Outbreaks/ clusters and multidrug resistant isolates associated with NHS Highland The closure of ward 1 Belford Hospital for 7 days occurred between 16/5/17 24/5/17 due to respiratory symptoms in 7 patients. Influenza B was confirmed in four patients. 6. Surveillance 6.1 MRSA Clinical Risk Assessment (CRA) Screening Audit In 2010 Health Protection Scotland provided a Clinical Risk Assessment tool comprising of three questions, to NHS Boards in order to ensure a consistent risk-based approach to mandatory MRSA swab screening is undertaken. As part of the national mandatory MRSA screening Programme, quarterly compliance data is submitted by NHS Boards to provide assurance that Clinical Risk Assessment (CRA) compliance is at or above 90%. MRSA Key Performance Indicator Compliance % 2014/ Q4 2015/ Apr- Q1 2015/ t Q2 2015/ Q3 / Q4 / - Q1 / t Q2 / Q3 / 2018 Q4 NHS Highland NHS Scotland 71% 75% 72% 78% 76% 84% 86% 86% 77% 78% 83% 78% 83% 80% 82% 84% 82% 79% The Infection Prevention and Control clinical risk assessment (CRA) tool which includes the MRSA clinical risk assessment and screening process are embedded into the common admission document. Staff are required to complete a CRA on all acute admissions as per the defined criteria. Monitoring of compliance by the Infection Prevention and Control Nurses occurs across NHS Highland, and areas with poor compliance are provided with additional support to ensure compliance. Quarter 4 data has identified a reduction in compliance; a high number of new staff in the ward areas has been identified as a possible reason. This is being addressed with the local teams by the Lead Nurse and the local Infection Prevention and Control groups through education. 6.2 Escherichia coli (E.Coli) Bacteraemia surveillance As of 1 st of the surveillance of Escherichia coli (E. Coli) Bacteraemia became a mandatory requirement for all NHS Boards to undertake. Data is collected by the Infection Prevention and Control Team in conjunction with the relevant clinical teams, and cases discussed to identify learning. The data collected and presented below highlights the local case numbers. Figure 6: Funnel plot of EColi bacteraemia (ECB) incidence rates (per Total Occupied bed days) in healthcare associated infection cases for all NHS boards in Scotland in Q1. NHS Forth Valley and NHS Highland overlap
11 HG NHS Highland NHS Highlands position as of 31 st (data not yet validated by HPS) is tabled below. 1st Total Cases = st Hospital Acquired = 4 (10%) Healthcare Associated = 9 (23%) Community Associated = 26 (67%) Not Known = 0 (0%) Under investigation = 0 (0%) It should be noted that the majority of E.Coli cases reported within NHS Highland are identified as community associated and are not related to urinary catheters or deemed preventable. Often they are associated with chronic urinary tract problems such as renal impairment and kidney stones. 6.3 Surgical Site Infections (SSI) NHS Highland continues to monitor SSI rates through mandatory and voluntary surveillance. The RAIGMORE clinical teams 30 alongside DAYS READMISSION the Infection Prevention ELECTIVE & Control COLORECTAL Surveillance team SSI and the Scottish Patient Safety Programme team (Acute adult workstream: SSI) are working jointly to review incidents of Colorectal infection, and SSI ensure rate for that - care practices is are 13.3%, evidence compared based and to maintained rate of 9.1%. Figure 7: highlights the monthly SSI rate elective colorectal SSI percentage and is annotated to identify when improvements have been introduced or compliance achieved Raigmore Monthly SSI rate following elective colorectal surgery SP TP SPSP SK NC A&T D & AA EM date SSI% Base line median extended median 11
12 KEY FOR GRAPH ANNOTATION Chloroprep skin prep SP Mar-13 Closure Tray, Tegaderm & pad TP Jun-13 SPSP SPSP -14 New Consultant NC Mar-15 Skin Prep 100% compliance SK -15 Prophylactic Abx compliance >90% A&T Mar-15 Temperature >36º C compliance >80% A&T Mar-15 Mr Docherty left D -15 Theatre Tech bundle TT -15 New Surgeon Ali Amin AA -16 Definition of Emergency changed EM Apr-17 Colorectal SSI rate was 13.3%. This compares to previous rates of %; %; and %; currently there have been 5 infections reported from 45 procedures between to (11% SSI rate). The monthly Colorectal improvement meeting have been reinstated. Rapid root cause analysis will be conducted on all SSI s and action plans will be developed where required. RAIGMORE 30 DAYS READMISSION ORTHOPAEDIC SSI Total Hip replacement (THR) surgery continues to have a low rate of SSI. Currently there are no infections have been reported in (0% rate of SSI). The THR SSI rate was 0.24%. This compares to previous rates of %; %; and %. Figure 8: Monthly SSI rate in Total Hip Replacement surgery % of infection NHSH Monthly SSI rate for Total Hip Replacement 2010 to Date SSI% Hemi-arthroplasty surgery continues to have a low rate of SSI. Currently there has been 1 infection reported from 63 procedures between to (1.6% SSI rate). SSI rate was 0%. This compares to previous rates of %; %; and %.
13 Figure 9: Monthly SSI rate for Hemi arthroplasty surgery 2010 to 20 NHSH Monthly SSI rate for Hemi Arthroplasty 2010 to 15 % of infection SSI% Neck of femur excluding Hemi-arthroplasty surgery continues to have a low rate of SSI. On the 31 st it had been 630 days since the last surgical site infection. - data identifies a rate of 0%. This compares to previous rates of %; %; %). Surveillance on these procedures within NHS Highland ended on 31 st. Figure 10: Monthly SSI rate for fracture Neck of Femur (#NOF) excluding hemi-arthroplasty 2010 to 31 st Mar % of infections NHSH Monthly SSI rate for #NOF 2010 to (excluding Hemi arthroplasty) Surveillance suspended Date SSI % NHSH 10 DAYS POST DISCHARGE CAESAREAN SECTION SSI Elective C-Section Currently 3 infections have been reported in with 122 operations performed (2.5% rate of SSI). SSI rate for - is 2.7%. This compares to previous rates of %; %; and %. 13
14 Figure 11: shows monthly SSI rate for elective C Sections, 2012 to % of infections NHSH SSI rate for elective C Sections 2012 to Date Percentage of infections median extended median Emergency C-Section Currently 5 infections have been reported in with 111 operations performed (4.5% rate of SSI). SSI rate for - is 2.4%. This compares to previous rates of %; %; and %. Figure 12: Monthly SSI rate for emergency C Section, 2012 to % of infections NHSH SSI rate for emergency C Sections 2012 to No Infections date % infections Bi monthly multi-disciplinary RCA meetings are held between the midwifery, obstetric, theatre and infection control team to review all C-section s resulting in an SSI. The SSI action plan continues to be implemented, and monitored through the SSI group. The Surgical site infection prevention bundle continues to be tested and implemented within the Theatre department. Currently a review of theatre drapes is underway in light of a larger body mass index being associated with recent SSI cases.
15 Healthcare Associated Infection Reporting Template (HAIRT) Section 2 Healthcare Associated Infection Report Cards The following section is a series of Report Cards that provide information, for each acute hospital and key community hospitals in the Board, on the number of cases of Staphylococcus aureus blood stream infections and Clostridium difficile infections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. Understanding the Report Cards Infection Case Numbers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. SAB cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). For each hospital the total number of cases for each month, been reported as positive from a laboratory report, on samples taken more than 48 hours after admission. Understanding the Report Cards Hand Hygiene Compliance Hospitals carry out regular audits of how well their staff are complying with hand hygiene. Each hospital report card presents the combined percentage of hand hygiene compliance with both opportunity taken and technique used broken down by staff group. Understanding the Report Cards Cleaning Compliance Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates compliance audits. Understanding the Report Cards Out of Hospital Infections CDI and SAB (including MRSA) bacteraemia cases are presented as Out of Hospital Infections and are not attributable to a hospital. This section identifies those infections from community sources such as GP surgeries and care homes, and those from positive samples taken from patients within 48 hours. Abbreviations SAB Definitions Definitions: Hospital acquired infection (HAI): Positive blood culture obtained from a patient who has been hospitalised for 48 hours. OR patient was transferred from another hospital, the duration of in-patient stay is calculated from the date of the first hospital admission. OR If the patient was a neonate/baby who has never left hospital since being born. OR The patient was discharged from hospital in the 48hr prior to the positive blood culture being taken. OR A patient who receives regular haemodialysis as an out-patient. OR Contaminant if the blood aspirated in hospital Healthcare associated infection (HCAI): Positive blood culture obtained from a patient within 48 hours of admission to hospital and fulfils one or more of the following criteria: 1. Was hospitalised overnight in the 30 days prior to the positive blood culture being taken. 2. Resides in a nursing, long term care facility or residential home. 3. IV, or intra-articular medication in the 30 days prior to the positive blood culture being taken, but excluding IV illicit drug use. 4. Regular user of a registered medical device e.g. intermittent self-catheterisation, home CPD or PEG tube with or without the direct involvement of a healthcare worker (excludes haemodialysis lines see HAI). 5. Underwent any medical procedure which broke mucous or skin barrier i.e. biopsies or dental extraction in the 30 days prior to the positive blood culture being taken. 6. Underwent care for a medical condition by a healthcare worker in the community which involved contact with non-intact skin, mucous membranes or the use of an invasive device in the 30 days prior to the positive blood culture being taken e.g. podiatry or dressing of chronic ulcers, catheter change or insertion. Community infection: Positive blood culture obtained from a patient within 48 hours of admission to hospital who does not fulfil any of the criteria for healthcare associated bloodstream infection. Not known: Only to be used if the SAB is not an HAI, and unable to determine if Community or HCAI. 15
16 CDI definitions Definitions: Healthcare-associated CDI: a case with onset of symptoms on day three or later, following admission to a healthcare facility on day one, OR in the community within four weeks of discharge from any healthcare facility. This may apply to the current hospital or a previous stay in another healthcare facility, e.g. in another hospital, a long-term care facility or other healthcare facilities (e.g. outpatient departments etc.) Community-associated CDI: a case with [onset outside of healthcare facilities, AND without discharge from a healthcare facility within the previous 12 weeks] OR [onset on the day of admission to a healthcare facility or on the following day AND not resident in a healthcare facility within the previous 12 weeks] Unknown association: a case who was discharged from a healthcare facility 4 12 weeks before symptom onset ADTC Area Drugs & Therapeutics Committee AMAU Acute Medical Admissions Unit CDI Clostridium difficile Infection CNO Chief Nursing Officer HEAT Health Improvement, Efficiency, Access, Treatment GDP General Dental Practitioner HAI QIF Healthcare Associated Infection Quality Improvement Facilitator HPS Health Protection Scotland JAG Joint Advisory Group CPE Carbapenemase-producing Enterobacteriaceae PICC Peripherally Inserted Central Catheter PVC Peripheral Venous Catheter PPI Proton Pump Inhibitor RIDDOR Reporting of Injuries, Diseases & Dangerous Occurrences Regulations 1995 SHPN Scottish Health Planning Note SICPs Standard Infection Control Precautions IPCT Infection prevention & control team AMT Antimicrobial Prescribing Team CHP Community Health Partnership CMO Chief Medical Officer CVC Central Venous Catheter ECDC European Centre for Disease Prevention & Control HAI Healthcare Associated Infection HAIRT Healthcare Associated Infection Reporting Template HSE Health and Safety Executive HFS Health Facilities Scotland MRSA Meticillin Resistant Staphylococcus Aureus MSSA Meticillin Sensitive Staphylococcus Aureus SAB Staphylococcus aureus Bacteraemia SPC Statistical Process Chart Hemiarthroplasty: Operation to treat fractured hip (only involves half of hip) SHTM Scottish Health Technical Memoranda SAPG Scottish Antimicrobial Prescribing Group SPSP Scottish Patient Safety Programme
17 NHS HIGHLAND REPORT CARD NHS Highland Staphylococcus aureus bacteraemia (SABs) monthly case numbers 15 SAB's NHS Highland MRSA MSSA Total SABS Aug Mar- Apr- Jun-15 Jul-15 Aug Mar- Apr- Jun-16 Jul-16 Aug Mar- Apr- MRSA MSSA Total SABS NHS Highland Clostridium difficile infection monthly case numbers C.difficile NHS Highland Aug Mar-15 Apr Jun-15 Jul-15 Aug Mar-16 Apr Jun-16 Jul-16 Aug Mar-17 Apr
18 Hand Hygiene Monitoring Compliance (%) Board Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Board Total Estates Monitoring Compliance (%) Board Total
19 NHS HIGHLAND RAIGMORE HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Estates Monitoring Compliance (%) Total
20 NHS HIGHLAND CAITHNESS GENERAL HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Total Estates Monitoring Compliance (%) Total
21 NHS HIGHLAND BELFORD HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Total Estates Monitoring Compliance (%) Total
22 NHS HIGHLAND LORN & ISLANDS HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Total Estates Monitoring Compliance (%) Total
23 NHS HIGHLAND NORTH & WEST OPERATIONAL UNIT COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Dunbar Hospital, Thurso Town & County Hospital, Wick Lawson Memorial Hospital Golspie Migdale Hospital, Bonar Bridge MacKinnon Memorial Hospital, Broadford Portree Hospital, Isle of Skye Staphylococcus aureus bacteraemia monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Total Estates Monitoring Compliance (%) Total
24 NHS HIGHLAND SOUTH & MID OPERATIONAL UNIT COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Ross Memorial Hospital, Dingwall County Community Hospital, Invergordon Royal Northern Infirmary Community Hospital, Inverness Town & County Hospital, Nairn Ian Charles Hospital, Grantown on Spey St Vincent s Hospital, Kingussie For the purposes of monitoring New Craigs Psychiatric Hospital is included in this report card. Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Total Estates Monitoring Compliance (%) Total
25 NHS HIGHLAND ARGYLL & BUTE CHP COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Argyll & Bute Hospital Lochgilphead Campbeltown Hospital Cowal Community Hospital, Dunoon, Dunaros Community Hospital, Isle of Mull Islay Hospital Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead Victoria Hospital & Annex, Rothesay Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Hand Hygiene Monitoring Compliance (%) Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Total Estates Monitoring Compliance (%) Total
26 NHS HIGHLAND OUT OF HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers
NHS Highland Infection Prevention & Control Annual Work Plan End of Year
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
More informationHEALTHCARE ASSOCIATED INFECTION PREVENTION AND CONTROL REPORT JUNE 2016
Appendix--75 Borders NHS Board HEALTHCARE ASSOCIATED INFECTION PREVENTION AND CONTROL REPORT JUNE Aim The purpose of this paper is to update Board members of the current status of Healthcare Associated
More informationReport by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead, Infection Prevention & Control
INFECTION PREVENTION & CONTROL ANNUAL WORK PLAN (2013 2014) Highland NHS Board 4 June 2013 Item 5.5(c) Report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive
More informationReport by Liz McClurg, Interim Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control
INFECTION CONTROL REPORT Highland NHS Board 1 June 2 Item 4.5 Report by Liz McClurg, Interim Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control
More informationBoard Meeting 01/12/16 Open Session Item 10. Performance and Quality Report to the Board December 2016
Board Meeting 01/12/16 Open Session Item 10 Performance and Quality Report to the Board ember Introduction This report summarises key areas of performance which includes, but is not limited to, Local Delivery
More informationSUBJECT: Healthcare Associated Infection (HCAI) Reporting Template
Meeting of Lanarkshire NHS Board: 31 uary 2018 Lanarkshire NHS Board Kirklands Bothwell G71 8BB Telephone: 098 855500 www.nhslanarkshire.org.uk SUBJECT: Healthcare Associated Infection (HCAI) Reporting
More informationHealthcare Associated Infection Reporting Template (HAIRT) The NHS Board is asked to note the latest 2 monthly report on HAI within NHSGGC
NHS Meeting 17 th ruary 2015 Medical Director Paper No.15/04 Recommendation: Healthcare Associated Infection Reporting Template (HAIRT) The NHS is asked to note the latest 2 monthly report on HAI within
More informationHEI self-assessment. Completing the self-assessment - Guidance to NHS boards
HEI self-assessment Completing the self-assessment - Guidance to NHS boards INTRODUCTION This document should be read in conjunction Healthcare Improvement Scotland healthcare associated infection (HAI)
More informationPrevention and Control of Infection Annual Report 2014/15
Golden Jubilee Foundation Prevention and Control of Infection Annual Report 20/ Approval record Date approved Board Prevention and Control of Infection Committee 11 September 20 Clinical Governance Risk
More informationThe safety of every patient we care for is our number one priority
HUMBER NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL STRATEGY 2015-2017 1. Introduction Healthcare associated infections (HCAI) continue to be a major cause of patient harm and although nationally
More informationPrevention and control of healthcare-associated infections
Prevention and control of healthcare-associated infections Quality improvement guide Issued: November 2011 NICE public health guidance 36 guidance.nice.org.uk/ph36 NHS Evidence has accredited the process
More informationTRUST BOARD. Date of Meeting: 05/10/2010
TRUST BOARD Date of Meeting: 05//20 Enclosure: 7 Agenda Item No: 8.3 Title of Report: Interim Report for Infection Prevention and Control 20-2011 Aims: To inform the Board of the work of the Trust in controlling
More informationPublic health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36
Healthcare-associated infections: prevention ention and control Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36 NICE 2017. All rights reserved. Subject to Notice of rights
More informationClostridium difficile Infection (CDI) Trigger Tool
Hospital ward/clinical Area Date Trigger Tool Commenced Date Trigger Tool Closed Person closing the CDI Trigger Health Protection Scotland March 2014 Version 3.0 A CDI trigger is the number of new CDI
More informationEstablishing an infection control accreditation programme to control infection
International Journal of Infection Control www.ijic.info ISSN 1996-9783 Establishing an infection control accreditation programme to control infection Julie Parker Sheffield Teaching Hospitals NHS Foundation
More informationWRIGHTINGTON, WIGAN AND LEIGH HEALTH SERVICES NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT
WRIGHTINGTON, WIGAN AND LEIGH HEALTH SERVICES NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2006-2007 Author(s) Gill Harris, Director of Infection Prevention and Control EXECUTIVE
More informationClostridium difficile Infection (CDI) Trigger Tool
Hospital ward/clinical Area Date Trigger Tool Commenced Date Trigger Tool Closed Person closing the CDI Trigger Health Protection Scotland V2.0 November 2011 A CDI Trigger is the point at which the Infection
More informationJob Title 22 February 2013
Surveillance of Infection Policy HH(1)/IC/613/13 Previous document(s) being replaced Location Policy Policy Name RHCH CP021 Surveillance Policy BNHH IC/289/09 Surveillance of Infection Protocol Document
More informationTom Walsh Infection Control Manager May 2008 ANNUAL INFECTION CONTROL REPORT 2007/08
Tom Walsh Infection Control Manager May 2008 ANNUAL INFECTION CONTROL REPORT 2007/08 CONTENTS 1. INTRODUCTION... 1 2. ACCOUNTABILITY ARRANGEMENTS FOR PREVENTION & CONTROL OF INFECTION WITHIN NHSGGC...
More informationCarbapenemase Producing Enterobacteriaceae (CPE) Prevention and Management Toolkit for Inpatient Areas
Carbapenemase Producing Enterobacteriaceae (CPE) Prevention and Management Toolkit for Inpatient Areas This toolkit includes examples advice leaflets and forms which may be helpful for use by teams or
More informationInfection Prevention & Control
Infection Prevention & Control Annual Report 2016-2017 Approved by the Lanarkshire Infection Control Committee 12 July 2017 REP.IPCTAR.17_11563.L Infection Prevention & Control Annual Report 2017 - Page
More informationConsumers Union/Safe Patient Project Page 1 of 7
Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several
More informationAntimicrobial stewardship in Scotland: quality improvement agenda
Antimicrobial stewardship in Scotland: quality improvement agenda Dr Jacqueline Sneddon Project Lead Scottish Antimicrobial Prescribing Group Background Scottish Antimicrobial Prescribing Group (SAPG)
More informationInfection Prevention. & Control. Report
Infection Prevention & Control Report April 2012 March 2013 Author Joanne Raper, Infection Prevention & Control Nurse Manager Page 1 of 10 1.0 Purpose of the Paper The purpose of this report is to provide
More informationNHS LANARKSHIRE QUALITY DASHBOARD Board Report June 2011 (Data available as at end April 2011)
NHS LANARKSHIRE QUALITY DASHBOARD Board Report June 2011 (Data available as at end April 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with the
More informationInfection Prevention and Control. Quarterly Report
Infection Prevention and Control Quarterly Report 1 st July 2009 30 th September 2009 Dr Nick Harper Director of Infection Prevention and Control Mrs Johanne Lickiss Nurse Consultant Infection Prevention
More informationConnolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March 2013
Connolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March 2013 1. Summary The Infection Prevention and Control Quality Improvement Plan clearly defines the priorities for
More informationBOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013
Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health
More informationSHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY: BOARD OF DIRECTORS 22 FEBRUARY 2012
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY: BOARD OF DIRECTORS C 22 FEBRUARY 2012 Subject: Supporting : Author: Status (see footnote): Update on the Clostridium difficile (C.diff)
More informationINFECTION CONTROL SURVEILLANCE POLICY
INFECTION CONTROL SURVEILLANCE POLICY Version: 3 Ratified by: Date ratified: July 2016 Title of originator/author: Title of responsible committee/group: Senior Managers Operational Group Head of Infection
More informationAyrshire and Arran NHS Board
Paper 6 Ayrshire and Arran NHS Board Monday 11 December 2017 SPSP Update: Acute Adult Programme Author: Laura Harvey, QI Lead for Acute Services, Person Centred & Customer Care Sponsoring Director: Liz
More informationReducing the risk of healthcare associated infection
i Reducing the risk of healthcare associated infection Healthcare associated infection Introduction The Royal Marsden takes the safety of our patients very seriously. That means doing everything we can
More informationReport of the unannounced inspection at Wexford General Hospital.
Report of the unannounced inspection of the prevention and control of healthcare associated infection at X Hospital Report of the unannounced inspection at Wexford General Hospital. Monitoring programme
More informationQuality and Safety Committee. Prevention and Control of Healthcare Acquired Infections performance to February 2012
Betsi Cadwaladr University Health Board Committee Paper 05.04.12 Item QS12/37.5 Name of Committee: Subject: Summary or Issues of Significance National / Local Objectives Addressed: Legislation or Healthcare
More informationBoard of Directors Infection Prevention and Control Report. Dr Claire Thomas, DIPC
Board of Directors 25 November Report to: Title: Author: Sponsoring Director Purpose: Decision Sought: Board of Directors Infection Prevention and Control Report Dr Claire Thomas, DIPC Donna Green 6 monthly
More informationPublic Services Reform (Scotland) Bill. Scottish Independent Hospitals Association
Public Services Reform (Scotland) Bill Scottish Independent Hospitals Association The following submission is presented to the Health and Sport Committee of the Scottish Government as an outline of the
More informationMRSA: National developments, Progress, Challenges and Targets
MRSA: National developments, Progress, Challenges and Targets Professor Brian Duerden Inspector of Microbiology and Infection Control, Department of Health, London The MRSA challenge - 2007 Bacteraemia
More informationProvincial Surveillance
Provincial Surveillance Provincial Surveillance 2011/12 Launched first provincial surveillance protocols Establishment of provincial data entry & start of formal surveillance reports Partnership with AB
More informationHCAI Data Capture System User Manual. Case Capture: Main Data Collections
User Manual Case Capture: Main Data Collections About Public Health England Public Health England exists to protect and improve the nation's health and wellbeing, and reduce health inequalities. It does
More informationSurveillance of Surgical Site Infection Annual Report For procedures carried out from: January December 2014
Surveillance of Surgical Site Infection Annual Report For procedures carried out from: January 2010 - December 2014 Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP) Health Protection
More informationReducing the risk of healthcare associated infection
i Reducing the risk of healthcare associated infection Healthcare associated infection Introduction The Royal Marsden takes the safety of our patients very seriously. That means doing everything we can
More informationInfection Prevention and Control Strategy (NHSCT/11/379)
Infection Prevention and Control Strategy (NHSCT/11/379) September 2010 September 2010 Contents Page No. 1. Foreword 1 2. Introduction 2-3 3. Key Principles 4-5 4. Objectives 6-13 5. Organisational Arrangements
More informationabc INFECTION CONTROL STRATEGY
abc INFECTION CONTROL STRATEGY 1. INTRODUCTION East and North Hertfordshire NHS Trust (ENHT) considers the reduction of Healthcare Associated infections (HCAI) a key component of patient safety systems
More informationInspection Report. Royal Infirmary of Edinburgh. NHS Lothian 18 and 19 January February 2010
Inspection Report Royal Infirmary of Edinburgh NHS Lothian 18 and 19 January 2010 2 February 2010 qüé=eé~äíüå~êé=båîáêçåãéåí=fåëééåíçê~íé=áë=~=é~êí=çñ=kep=nì~äáíó=fãéêçîéãéåí=påçíä~åç= The Healthcare Environment
More informationStaphylococcus aureus bacteraemia in Australian public hospitals Australian hospital statistics
Staphylococcus aureus bacteraemia in Australian public hospitals 2013 14 Australian hospital statistics Staphylococcus aureus bacteraemia (SAB) in Australian public hospitals 2013 14 SAB is a serious bloodstream
More informationOPTIONS APPRAISAL PAPER FOR DEVELOPING A SUSTAINABLE AND EFFECTIVE ORTHOPAEDIC SERVICE IN NHS WESTERN ISLES
Highland NHS Board 9 August 2011 Item 4.3 OPTIONS APPRAISAL PAPER FOR DEVELOPING A SUSTAINABLE AND EFFECTIVE ORTHOPAEDIC SERVICE IN NHS WESTERN ISLES Report by Sheila Cascarino, Divisional Manager, Surgical
More informationInfection Prevention & Control Annual Report 2011/2012
Infection Prevention & Control Annual Report 2011/2012 Board of Directors Approval date: 1 November 2012 Infection Prevention & Control Committee Submission date: 1 August 2012 Position at 31 March 2012
More informationHealthcare-Associated Infections
Healthcare-Associated Infections A healthcare crisis requiring European leadership Healthcare-associated infections (HAIs - also referred to as nosocomial infections) are defined as an infection occurring
More informationREPORT SUMMARY SHEET
Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: High level context: Trust Board 29 th September 2016 Infection Prevention and Control
More informationSurveillance of Surgical Site Infection Annual Report
Surveillance of Surgical Site Infection Annual Report For procedures carried out from: January 2008 - December 2012 Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP) Health Protection
More informationHEALTHCARE ASSOCIATED INFECTIONS RISK ASSESSMENT PROCEDURE
HEALTHCARE ASSOCIATED INFECTIONS RISK ASSESSMENT PROCEDURE Author: Jenny Boyce, Lead Infection Prevention & Control Nurse Approved by and date: March 2016 Any other linked ICP 000 - Infection Prevention
More informationReport of the unannounced inspection at the Mater Misericordiae University Hospital, Dublin.
Report of the unannounced inspection of the prevention and control of healthcare associated infection at X Hospital Report of the unannounced inspection at the Mater Misericordiae University Hospital,
More informationPolicy elibrary Reference No: Date of Issue: June Date of Review: 23 rd May Version: November 2016
NHS Highland Board 30 May 2017 Item 4.8 NHS HIGHLAND LOCAL PATIENT ACCESS POLICY Policy elibrary Reference No: Date of Issue: June 2013 Prepared by: Margaret Brown, Business Support Directorate Donna Smith,
More informationNHS Tayside INFECTION CONTROL. Infection Prevention and Control Scorecard Strategy 2009/10. Information for Clinical Groupings including CHPs
NHS Tayside INFECTION CONTROL Infection Prevention and Control Scorecard Strategy 29/ Information for Clinical Groupings including CHPs Author: Gabby Phillips Review Group: Infection Control SMT Review
More informationREPORT SUMMARY SHEET
Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: High level context: Trust Board 27 th October 2016 Infection Prevention and Control
More informationChecklists for Preventing and Controlling
Checklists for Preventing and Controlling Clostridium difficile Infection (CDI) This document has been developed to specifically assist senior management and all ward staff to take appropriate actions,
More informationAnnual Infection Prevention and Control Report Produced by Colette Thomas Lead Nurse Infection Prevention and Control Page 1
Infection Prevention And Control Annual Report 2014-2015 Presented by: Written and Compiled by: Contributors: Executive Lead: Director of Infection Prevention and Control Lead Nurse, Infection Prevention
More informationHCAI Local implementation team action plan
HCAI Local implementation team action plan Item Type Report Authors New Governance HCAI Group Publisher New Governance HCAI Group Download date 16/09/2018 18:12:09 Link to Item http://hdl.handle.net/10147/110814
More informationIntensive Psychiatric Care Units
NHS Highland Argyll & Bute Hospital, Lochgilphead Intensive Psychiatric Care Units Service Profile Exercise ~ November 2009 NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity.
More informationThis is a high level overview report to update the Board on the Acute Adult Safety Programme consisting of the following sections:
Greater Glasgow and Clyde NHS Board Board Meeting June 2014 Board Paper No. 14/34 Board Medical Director Scottish Patient Safety Programme Update 1. Background The Scottish Patient Safety Programme (SPSP)
More informationHealthcare associated infections across the health and social care community
Healthcare associated infections across the health and social care community Professor Brian Duerden CBE Inspector of Microbiology and Infection Control, Department of Health, London Infection is different..it
More informationThe prevention, management and control of Healthcare Associated Infections (HCAI) in hospitals (ROCR-LITE/08/014/FT6)
NATIONAL AUDIT OFFICE STUDY The prevention, management and control of Healthcare Associated Infections (HCAI) in hospitals (ROCR-LITE/08/014/FT6) National Audit Office study The prevention, management
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationINFECTION PREVENTION & CONTROL ANNUAL REPORT 2016 / 2017
INFECTION PREVENTION & CONTROL ANNUAL REPORT 1 2016 / 2017 AUTHOR Mustafa Ahmed Governance Improvement Manager DIRECTOR OF INFECTION PREVENTION & CONTROL Garry Marsh Executive Director of Patient Services
More informationThe National Standards for the Prevention and Control of Healthcare Associated Infection
The National Standards for the Prevention and Control of Healthcare Associated Infection The View of the Regulator Sean Egan Inspector Manager, HIQA Presentation Overview The role and function of the Health
More informationINFECTION PREVENTION & CONTROL. ANNUAL REPORT Northern Devon Healthcare NHS Trust
INFECTION PREVENTION & CONTROL ANNUAL REPORT 2013-14 Northern Devon Healthcare NHS Trust incorporating community services in Exeter, East and Mid Devon 1 Kevin Marsh David Richards Joint Directors of Infection
More informationPublic Board Meeting January 2018 Item No 11 THIS PAPER IS FOR DISCUSSION PATIENT AND STAFF SAFETY HEALTHCARE ASSOCIATED INFECTION (HAI) UPDATE REPORT
NOT PROTECTIVELY MARKED Public Board Meeting January 2018 Item No 11 THIS PAPER IS FOR DISCUSSION PATIENT AND STAFF SAFETY HEALTHCARE ASSOCIATED INFECTION (HAI) UPDATE REPORT Lead Director Author Action
More informationAnnual Infection Prevention & Control Report Infection Prevention & Control is everyone s business
Annual Infection Prevention & Control Report 2013-2014 Infection Prevention & Control is everyone s business Infection Prevention and Control Committee August 2014 Contents Page Executive Summary Surveillance
More informationHealthcare Associated Infection Policy for Staff Working in NHS Grampian
Healthcare Associated Infection Policy for Staff Working in NHS Grampian Lead Author/Coordinator: Pamela Harrison, Infection Prevention and Control Manager Reviewer: Amanda Croft, HAI Executive Lead Approver:
More informationThe Strategic HAI Agenda. Dr R G Masterton Executive Medical Director
The Strategic HAI Agenda Dr R G Masterton Executive Medical Director HAI as Big Business Overall prevalence of HAI in acute hospitals = 9.5% (8.8% 10.2% 95% CI). Urinary Tract Infections = 17.9% of all
More informationShetland NHS Board. Control of Infection Committee Annual Report
Shetland NHS Board Control of Infection Committee Annual Report April 20- March 2009 1 Acronyms and Abbreviations ARI AOBD CDU CoIC CSBS HAI HAI SCRIBE HDL HEAT targets HPS ICT NES MMR PFPI PPE MRSA MSSA
More informationKey prevention strategies for MRSA bacteraemia: a case study. Dr. Michael A. Borg Director of Infection Prevention & Control Mater Dei Hospital Malta
Key prevention strategies for MRSA bacteraemia: a case study Dr. Michael A. Borg Director of Infection Prevention & Control Mater Dei Hospital Malta 1 Mortality following Staphylococcus aureus bacteraemia
More informationUnannounced Theatre Inspection Report
Unannounced Theatre Inspection Report Perth Royal Infirmary NHS Tayside 12 13 July 2017 www.healthcareimprovementscotland.org The Healthcare Environment Inspectorate was established in April 2009 and is
More informationInfection Prevention and Control (IPC) Annual Programme 20010/11
Infection Prevention and Control (IPC) Annual Programme 20010/11 1. Introduction The Code of Practice for the Prevention and Control of Healthcare Associated Infections (DH, 2009) otherwise known as the
More informationNational Hand Hygiene NHS Campaign
National Hand Hygiene NHS Campaign Compliance with Hand Hygiene - Audit Report Your Questions Answered Germs. Wash your hands of them Prepared for the Scottish Government Health Directorate HAI Task Force
More informationNHS GRAMPIAN. Local Delivery Plan - Section 2 Elective Care
NHS GRAMPIAN Local Delivery Plan - Section 2 Elective Care Board Meeting 01/12/2016 Open Session Item 7 1. Actions Recommended The NHS Board is asked to: Consider the context in which planning for future
More informationHealthcare quality lessons from the best small country in the world
Healthcare quality lessons from the best small country in the world Scotland and Canada Scotland 5.5 Million people Scottish Politics Scottish Politics Devolution - 1997 Scottish National Party minority
More informationWest Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan [Updated 19/3/13] Item 37/13
Introduction purpose: West Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan 2012-2013 [Updated 19/3/13] Item 37/13 This action plan has been developed by West Hertfordshire
More informationAnnounced Inspection Report
Announced Inspection Report Udston Hospital NHS Lanarkshire 20 21 September 2017 www.healthcareimprovementscotland.org The Healthcare Environment Inspectorate was established in April 2009 and is part
More informationCLOSTRIDIUM DIFFICILE ACTION PLAN
CLOSTRIDIUM DIFFICILE ACTION PLAN Action plan to address the rise in cases of Clostridium difficile (C.diff) at Sheffield Teaching Hospitals NHS Foundation Trust ACTION KEY MILESTONES PERSON RESPONSIBLE
More informationNHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011)
NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with
More informationPrairie North Regional Health Authority: Hospital-acquired infections
Prairie North Regional Health Authority: Hospital-acquired infections Main points... 308 Introduction... 309 Background the risk of hospital-acquired infections... 309 Audit objective, scope, criteria,
More informationShetland NHS Board Control of Infection Committee Annual Report April March 2010 FINAL VERSION
Shetland NHS Board Control of Infection Committee Annual Report April 2009 - March 2010 FINAL VERSION NHS Shetland Control of Infection Committee Annual Report 2009-2010 Acronyms and Abbreviations ARI
More informationThis paper provides detail of actions to reduce the incidence of Clostridium difficile at Airedale NHS Foundation Trust (ANHST).
Airedale NHS Foundation Trust Board of Directors: 27 February 2013 Title: Update on Actions to Reduce the Incidence of Clostridium difficile at Airedale NHS Foundation Trust Author: Allison Charlesworth,
More informationPrevention and Control of Infection in Care Homes. Infection Prevention and Control Team Public Health Norfolk County Council January 2015
Prevention and Control of Infection in Care Homes Infection Prevention and Control Team Public Health Norfolk County Council January 2015 Content for today Importance of IPAC -refresher IPAC audits in
More informationInfection Prevention and Control Annual Report
Infection Prevention and Control Annual Report 2015-16 Infection Prevention and Control Annual Report 2015-16 CONTENTS EXECUTIVE SUMMARY... 1 1. INTRODUCTION... 3 2. INFECTION PREVENTION AND CONTROL ARRANGEMENTS...
More informationMandatory Surveillance of Healthcare Associated Infections Report 2006
Mandatory Surveillance of Healthcare Associated Infections Report 2006 Contents 1. Introduction...2 2. Key Points...3 3. Results of the fifth year of mandatory surveillance of MRSA bacteraemia, including
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationQUALITY REPORT. Part A Patient Experience
QUALITY REPORT Part A Patient Experience 1 Number of complaints Complaints and Patient Advice and Liaison Report 40 Total number of complaints received 30 20 10 Number of complaints received Trendline
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital Report for: Royal Wolverhampton NHS Trust January 2016 The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent
More informationCommissioning for Quality & Innovation (CQUIN)
Commissioning for Quality & Innovation () The following suite of s are goals relating to improvements in the quality of patient care which the Trust has agreed with commissioners (with the exception of
More informationThe prevention and control of infections North Cumbria University Hospitals NHS Trust
The prevention and control of infections North Cumbria University Hospitals NHS Trust Region: North West Provider s code: RNL Type of organisation: Acute trust Type of inspection: Enhanced Sites we visited:
More informationReducing Mortality and Harm in ABMU Local Health Board
10 th June 2011 Reducing Mortality and Harm in ABMU Local Health Board Insert name of presentation on Master Slide Programme Driver Diagram Aims/Outcome Measure Reduce Mortality Reduce RAMI to
More informationHealthcare Acquired Infections
Healthcare Acquired Infections Emerging Trends in Hospital Administration 9 th & 10 th May 2014 Prof. Hannah Priya HICC In charge What is healthcare acquired infection? An infection occurring in a patient
More informationProgress Report on C.Diff Action Plan
NHS GREATER GLASGOW AND CLYDE NHS Board Meeting 16 December 2008 Paper No. 08/55 Board Medical Director Progress Report on C.Diff Action Plan Recommendation The NHS Board is asked to receive this further
More informationAnnual Report Infection Prevention and Control. RDaSH. Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships
RDaSH Infection Prevention and Control Annual Report Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships Dr Deborah Wildgoose Deputy Director of Nursing and Standards Rachel Millard Head
More informationFor further information please contact: Health Information and Quality Authority
For further information please contact: Infection Prevention and Control 13-15 The Mall Beacon Court Bracken Road Sandyford Dublin 18 Phone: +353 (0)1 293 1140 Email: ipc@hiqa.ie URL www.hiqa.ie Guide
More informationHIQA s monitoring programme - National Standards for the Prevention and Control of Healthcare. theatre findings Katrina Sugrue Inspector HIQA
HIQA s monitoring programme - National Standards for the Prevention and Control of Healthcare Associated Infections: Operating theatre findings 205. Katrina Sugrue Inspector HIQA The Authority s role is
More informationReport of the announced monitoring assessment at Connolly Hospital, Blanchardstown, Dublin
Report of the announced monitoring assessment at Connolly Hospital, Blanchardstown, Dublin Monitoring Programme for the National Standards for the Prevention and Control of Healthcare Associated Infections
More informationOperational policy on Deactivating ICD s at End of Life.
Operational policy on Deactivating ICD s at End of Life. Northern NHS Highland Policy Reference: ICD deactivation policy Date of Issue: November 2012 Prepared by: Amanda Smith and Catriona MacDonald Date
More information