Infection Prevention & Control

Transcription

1 Infection Prevention & Control Annual Report Approved by the Lanarkshire Infection Control Committee 12 July 2017 REP.IPCTAR.17_11563.L Infection Prevention & Control Annual Report Page 1

2 The Team Management Team Irene Barkby, Executive Director Nursing, Midwifery and Allied Health Professionals (NMAHPs) Emer Shepherd, Head of Infection Prevention and Control (IPC) Clare Mitchell, Senior Nurse Babs Gemmell, Scrutiny and Assurance Manager Sarah Whitehead, Infection Control Doctor Administration Team Pauline Ferula, Administrative Lead Elaine Elder, Team Secretary Valerie Waugh, Team Secretary Clare Penrice, Data Co-ordinator IPC Nursing Team Linda Thomas, Clinical Nurse Specialist Carol Whitefield, Clinical Nurse Specialist Lee Macready, Clinical Nurse Specialist Richard Fox, Clinical Nurse Specialist Lyndsay Quarrell, IPC Nurse Nicola McLean, IPC Nurse Kaileigh Begley, IPC Nurse Sandra Burke, IPC Nurse Surveillance Team Liz Young, Lead Surveillance Nurse Julie Kerr, Surveillance Nurse Julie Burns, Surveillance Nurse Introduction Preventing and controlling Healthcare Associated Infection (HCAI) continues to be a challenge in healthcare on a global scale. The European Centres for Disease Control (ECDC) estimate that around 3.2 million patients develop an HCAI every year in Europe. Statistics from the most recent National Point Prevalence Survey (NPPS) of HCAI and Antimicrobial Prescribing completed in Scotland in 2016 demonstrates that: 1 in 22 acute adult inpatients had at least one HCAI; 1 in 37 paediatric inpatients had at least 1HCAI; and 1 in 31 non-acute adult inpatients had at least 1HCAI. The inpatient cost of HCAIs originating in Scottish acute care hospitals was estimated to be 137 million a year with an additional 318,172 bed days required in order to care for patients with HCAI; the equivalent of a large teaching hospital occupied for one year 1. A significant proportion of HCAIs are considered to be avoidable and prevention of these infections provides an opportunity to improve patient outcome and reduce unnecessary costs within healthcare systems 2. The purpose of this IPC Annual Report is to provide an overview of the IPC activities over the past twelve months highlighting key changes, challenges and service achievements along with identification of areas for improvement. 1 Health Protection Scotland. Healthcare Associated Infection Annual Report Glasgow, HPS; Available from haiic/sshaip/ resourcedetail.aspx?id= Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54(4): Page 2 - Infection Prevention & Control Annual Report 2017

3 Glossary of Terms ABHR Alcohol Based Hand Rub AMC Antimicrobial Management Committee AMR Antimicrobial Resistant AOCB Acute Occupied Bed Days BD Beckton Dickinson BSI Blood Stream Infection CAI Community Associated Infection CDI Clostridium difficile Infection CMT Corporate Management Team CPE Carbapenemase Producing Enterobacteriaceae CRA Clinical Risk Assessment CVC Central Venous Cannula DEMG Decontamination Environmental Monitoring Group ECB Escherichia coli Bacteraemia ECDC European Centre for Disease Control H&SCPs Health and Social Care Partnerships HCAI Healthcare Associated Infection HPC Health Protection Committee HPS Health Protection Scotland IDEAG Invasive Device Expert Advisory Group IMT Incident Management Team IPC Infection Prevention and Control IPCT Infection Prevention and Control Team IRIS Infection related intelligence service LDP Local Delivery Plan LICC Lanarkshire Infection Control Committee MRSA Meticillin resistant staphylococcus aureus MSSA Meticillin sensitive staphylococcus aureus NHS National Health Service NHSL NHS Lanarkshire NPPS National Point Prevalence Survey PDP Personal Development Plan PMS Patient Management System PRG Policy Review Group PVC Peripheral Venous Cannula PVL Panton-Valentine Leukocidin SAB Staphylococcus aureus bacteraemia s Standard Infection Control Precautions SOP Standard Operating Procedure SPSP Scottish Patient Safety Programme SPUD Surveillance Prevalence Update Daily SSIs Surgical Site Infections TBPs Transmission Based Precautions UTI Urinary Tract Infection VRE Vancomycin resistant enterococci WHO World Health Organisation WSG Water Safety Group *HEAT TARGETS KEY NHS Boards to achieve the Staphylococcus aureus Bacteraemia (SAB) HEAT target of 24 cases or less per 100,000 acute occupied bed days (AOBD) by 31 March This equated to no more than cases / 8.9 cases per month to achieve. NHS Boards to achieve the Clostridium difficile infection (CDI) HEAT target of 32 cases or less per 100,000 AOBD in the aged 15 and over age group by 31 March This equated to no more than cases / 13.4 cases per month to achieve. Infection Prevention & Control Annual Report Page 3

4 Executive Summary Clostridium difficile infection (CDI) CDI is an important HCAI, which usually causes diarrhoea and contributes to a significant burden of morbidity and mortality. Prevention of CDI is therefore essential and an important patient safety issue. HEAT Target: To achieve 32 CDI cases or less per 100,000 AOBD in the aged 15 and over age group by 31 March NHSL performance in 2016/2017: Incidence rate in patients aged 65 and above was 0.26 per 100,000 AOBDs (96 cases) Incidence rate in patients aged 15 years and above was 0.28 per 100,000 AOBDs (144 Cases) HEAT TARGET WAS ACHIEVED Hand Hygiene Hand Hygiene is recognised as being the single most important indicator of safety and quality of care in healthcare settings because there is substantial evidence to demonstrate the correlation between good hand hygiene practices and low healthcare associated infection rates confirmed by the World Health Organisation (WHO). NHSL performance in 2016/2017 achieved 86% against a national requirement of 95%. Surgical Site Infection (SSI) SSI is one of the most common HCAI and can cause increased morbidity and mortality and are estimated on average to double the cost of treatment, mainly due to the resultant increase in length of stay. SSI can have a serious consequence for patients affected as they can results in increased pain, suffering and in some cases require additional surgical intervention. NHSL performance in 2016/2017 Staphylococcus aureus Bactereamia (SAB) Staphylococcus aureus (S. Aureus) is a gram positive bacterium which colonises the nasal cavity of about a quarter of the healthy population. Infection can occur if S. Aureus breaches the body s defence system and can cause a range of illnesses from minor skin infections to serious systematic infections such as bacteraemia. HEAT TARGET: To achieve 24 SAB cases or less per 100,000 AOBDs by 31 March NHSL performance in 2016/2017: Incidence rate of SABs was 0.40 per 100,000 AODBs (180 cases) Incidence rate of MRSA was 0.01 per 100,000 AODBs (6 cases) Incidence rate of MSSA was 0.39 per 100,000 AODBs (174 cases) HEAT TARGET NOT ACHIEVED Outbreak Incidence The role of the IPC Team in healthcare is to prevent, prepare for, detect and manage outbreaks of infection. In 2016/2017 in NHSL there were: 73 separate outbreak situations; 34 in Monklands Hospital; 19 in Wishaw General Hospital; 14 in Hairmyres Hospital; and 6 in the H&SCPs 18 ward closures; 57 room restrictions 5 room closures lead to a full ward closure 327 closure days 305 patients; 134 staff affected 1.81% C-Section SSIs (1545 cases/28 SSIs) 0.70% Hip Arthroplasty SSIs (423 cases/4 SSI) 1.22% Knee Arthroplasty SSIs (492 cases/6 SSIs) 0.94% Repair of neck of Femur SSIs (316 cases/3 SSIs) Escherichia coli Bacteraemia (ECB) Gram negative bacteria are now an emerging threat to health worldwide. Bacteraemia develops usually as a complication of other infections, including urinary tract infection (UTI), surgery and use of medical devices including urinary catheters and vascular access devices (VAD). Mandatory ECB enhanced surveillance was implemented April In 2016/2017 there were 608 cases. The national reporting of ECBs started April 2017 therefore unable to provide a comparison. Vancomycin-resistant enterococci (VRE) VRE are a type of bacteria called enterococci that have developed resistance to many antibiotics especially Vancomycin. In 2016/2017, NHSL Ward 16 at Monklands Hospital has been identified as a high risk area for VRE due to the patient population. The IPCT implemented a number of control measures to reduce the burden of VRE within the environment therefore reducing the risk of cross transmission of infection. Page 4 - Infection Prevention & Control Annual Report 2017

5 Key Achievements Local Delivery Plan (LDP) Target for CDI was achieved with a rate of 0.28 (140 cases) in 2016/2017 against a national target rate of no more than The national year-end position across NHS Scotland was Sustained improvement with reduction of HCAI VRE bacteraemia rates in NHSL. Centralisation of the IPC Service to provide an expert led service to all sites across NHSL. Implementation of the Infection Related Intelligence Service (IRIS) in line with HAI Standards (2015) whilst achieving significant financial saving for the NHS Board. Implementation of the Pink Star Alert improving patient placement and reducing risk of cross transmission of infection. Increase in number of Nurses within IPCT accredited to Clinical Nurse Specialist level. Completion of situational assessment of invasive devices management across NHSL providing the Lanarkshire Infection Control Committee (LICC) with recommendations for improvement. Completion of all IPC related Vale of Leven Inquiry Scottish Government Actions. 95% completion of the LICC Annual Work Plan. Agreement of funding for a Band 7 Decontamination Clinical Specialist to support the organisation with decontamination related issues. Successful visit from the HAI Policy Unit at Scottish Government. Monitoring Programme Throughout 2016/2017, the monitoring programme centred on the IPC Nursing staff inspecting all wards/ clinical areas within NHSL over a 2 year period measuring performance against Standard Infection Control Precautions (s), Transmission Based Precautions (TBPs) and other relevant reviews to be undertaken to ensure adherence of policy to practice. MONITORING AUDIT PROGRAMME 1. Patient placement 2. Hand hygiene 3. Respiratory hygiene & cough etiquette 4. Personal protective quipment (PPE) 5. Safe management of patient care equipment 6. Control of the environment 7. Safe management of Linen 8. Safe management of blood & body fluid spillages 9. Safe disposal of waste (inc sharps) 10. Occupational exposure management 11. Patient equipment 12. Estates & facilities 13. Patient, public & staff information 14. Policies & staff education 15. PVC - invasive device compliance 16. CVC - invasive device compliance 17. Urinary catheter compliance Quarter 1 Quarter 2 Quarter 3 Quarter 4 Type JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Other Other Other Other Other Other Other Infection Prevention & Control Annual Report Page 5

6 Information Related Intelligence Service (IRIS) Each NHS Board in Scotland is mandated by the Standards for HCAI (2015) to have robust and effective surveillance systems of alert organisms and conditions in place to ensure rapid response to HCAI. In 2016/2017, the focus for the IPC Team (IPCT) was to build an annual surveillance programme that incorporates mandatory national and local surveillance of infections and alert conditions. Following approval by the Corporate Management Team (CMT) in early 2016, the IPCT designed a bespoke surveillance system using existing resources on a cost neutral basis delivering significant financial savings to the organisation in addition to enhancing patient safety. The Infection Related Intelligence Service (IRIS) is designed to ensure that surveillance activity across acute sites and health & social care partnership (H&SCPs) falls in line with the Standards for HAI (2015). A number of initiatives have been delivered as part of the implementation of IRIS including: The centralisation of the IPC Service to Wishaw General Hospital to pool resource and ensure safe and sustainable staffing of the service; The development of the Surveillance and Prevalence Update Daily (SPUD) which ensures robust communication across the team and to key stakeholders across the organisation; The design of a robust surveillance database to capture local intelligence and data that can be used to drive improvement and provide assurance in terms of performance against Local Delivery Plan (LDP) targets Enhanced communication with site Triumvirates and front line clinicians by delivery of performance scorecards from NHS Board to hospital level. Pink Star During the design of a bespoke surveillance system, lack of capacity to alert clinical teams to IPC risk was identified. The learning from a number of incidents including the Incident Management Teams (IMT) for Panton-Valentine Leukocidin (PVL) Meticillin resistant staphylococcus aureus (MRSA) demonstrated that the current alert on TrakCare was not fit for purpose. In June 2016, the IPCT launched the Pink Star. This is a bespoke electronic alert with exclusive access rights to members of the IPCT. Capacity was built into the current patient management system (PMS) to allow a daily pink star prevalence report to be mailed electronically to the IPCT so to assist with prevalence and identification of risk to the environment, patients, staff and visitors. By clicking on the pink star, staff can take appropriate steps to isolate the patient and carry out the necessary screening requirements reducing the risk of cross transmission of infection. The pink star alert appears on the TrakCare system identifying patients with alert organisms including: MRSA PVL MRSA CPE (Carbapenemase Producing Enterobacteriaceae) VRE Page 6 - Infection Prevention & Control Annual Report 2017

7 Staphylococcus aureus bacteraemia (SAB) When Staphylococcus aureus (S. Aureus) breaches the body s defence mechanisms, it can cause a wide range of illness from minor skin infections to serious infections such as bacteraemia or bloodstream infection. Local Delivery Plan (LDP) Target: All Scottish NHS Boards are required to achieve the SAB HEAT target of 24 cases or less per 100,000 acute occupied bed days (AOBD) by 31 March NHSL did not achieve the SAB HEAT Target for 2016/2017. NHSL achieved a rate of 0.40 against a national requirement of NHS Scotland year-end rate position in 2016/2017 was S.aureus bacteraemia 180 SAB cases 0.40 Annual incidence rate of SAB per 100,000 AOBDs. MRSA bacteraemia 6 MRSA cases 0.01 Annual incidence rate of SAB per 100,000 AOBDs MSSA bacteraemia 174 MSSA cases 0.39 Annual incidence rate of SAB per 100,000 AOBDs 88 HAI cases 40 HCAI cases 52 CAI cases Quality Improvement and interventions to reduce S.aureus infections: Enhanced surveillance and monitoring Admission screening SAB Rapid Reviews, sharing learning via Hygiene Teams Invasive Device Expert Advisory Group (IDEAG) to support SAB reduction strategies Completion of a situational assessment on vascular access devices during February / March 2017 identifying a number of themes for improvement. Scoping of screening patients for MSSA on admission. NEXT STEPS Via the work plan of the IDEAG, in 2017/18, the IPCT will support: Design of NHSL wide reference guides and protocols for management of invasive devices Pilot of mid lines in relevant speciality Review of procurement of invasive devices and associated equipment with a view to standardising kit and reducing risk of off licence use. Infection Prevention & Control Annual Report Page 7

8 Clostridium difficile Infection (CDI) CDI is an important HCAI, which usually causes diarrhoea and contributes to a significant burden of morbidity and mortality. Prevention of CDI is therefore essential and an important patient safety issue. Local Delivery Plan (LDP) Target: All Scottish NHS Boards are required to achieve the CDI HEAT target of 32 cases or less per 100,000 AOBD in the aged 15 and over age group by 31 March NHSL achieved the CDI HEAT Target in 2016/2017 with a rate of 0.28 against a national rate requirement of NHS Scotland year-end rate position in 2016/2017 was Patients 15 years and above 144 CDI cases 0.28 annual incidence rate of CDI per 100,000 AOBDs Patients aged 15 to CDI cases 0.33 annual incidence rate of CDI per 100,000 AOBDs Patients aged 65 years and 96 CDI cases 0.26 annual incidence rate of CDI per 100,000 AOBDs Quality Improvement and interventions to reduce CDIs: Enhanced surveillance and monitoring Implementation of CDI Severity Marker Guidance and casenote sticker Multi-disciplinary severe CDI case review to support improvement in assessment / detection for early intervention and patient management Good antimicrobial stewardship Proactive isolation of patients by frontline staff Antimicrobial Management Workbook Awareness campaigns, Winter Preparedness Road-shows 64 HCAI cases 75 CAI cases 5 Unknown Source Page 8 - Infection Prevention & Control Annual Report 2017

9 Surgical Site Infection (SSI) SSI is one of the most common HCAI and can cause increased morbidity and mortality and it is estimated on average to double the cost of treatment, mainly due to the resultant increase in length of stay. SSI can have a serious consequence for patients affected as they can results in increased pain, suffering and in some cases require additional surgical intervention. Caesarean Section 1545 Procedures carried out 28 SSIs following procedure 1.81% Infection Rate Hip Arthroplasty 423 Procedures carried out 4 SSIs following procedure 0.70% Infection Rate Knee Arthoplasty 492 Procedures carried out 6 SSIs following procedure 1.22% Infection Rate Repair of Neck of Femur 316 Procedures carried out 3 SSIs following procedure 0.94% Infection Rate Quality Improvement and interventions to reduce SSIs: Collaborative working Development of new reporting procedure Protocol to include new mandatory procedures Communication with medical and nursing staff DATIX Learning Next Steps From 1 April 2017, national mandatory standard surveillance for elective Colorectal (large bowel) and Vascular SSIs commenced. Surveillance Nurses flagged a variation on antibiotic prophylaxis in relation to colorectal procedures which has been addressed and will continue to be monitored in collaboration with antimicrobial pharmacists and highlighted via SPSP Peri-operative Workstream meeting. Further training and education requires to be undertaken particularly within maternity services. Refinement of process within the IPC Surveillance Nurses to improve data capture. Infection Prevention & Control Annual Report Page 9

10 MRSA Acute Inpatient Admission Screening A national MRSA acute inpatient admission screening policy has been in place in Scotland since March A clinical risk assessment (CRA) is completed for all acute inpatient admissions and against the screening policy identifies a subset of patients at high risk of MRSA colonisation or infection on admission to hospital who are then tested for MRSA. This method of screening reduces the number of patients who require to be laboratory tested for MRSA and allows high risk patients to be pre-emptively isolated whilst Local Delivery Plan (LDP) Target: Overall compliance was 74% against a national requirement of 90% or above. Escherichia coli (Ecoli) Bacteraemia (ECBs) Gram-negative bacteria continues to be an emerging threat in healthcare and in Scotland. In England in 2016, the incidence rate of E Coli bacteraemia per 100,000 population was 73.3 in Scotland for the same period the rate was Key themes from analysis of the data show demonstrate that over half of the cases reported to HPS are associated with the community with the biggest portion of infections reporting lower urinary tract infections as the source. In 2016 the all NHS Boards in Scotland commenced mandatory enhanced surveillance of E Coli bacteraemia as part of the national surveillance programme. A number of initiatives are currently being explored at national level with a view to reducing incidence rates including introduction of a Scottish Government performance target. The IPCT in NHSL will continue to work with national colleagues on improvement, cascading measures locally as appropariate. Total 608 Cases of EColi Bacteraemia during 2016/17 Page 10 - Infection Prevention & Control Annual Report 2017

11 Hand Hygiene Hand Hygiene is recognised as being the single most important indicator of safety and quality of care in healthcare settings. Hand Hygiene is a term used to describe the decontamination of hands by various methods including routine hand washing and/or hand disinfection which includes the use of alcohol gels and rubs. The 5 Moments for Hand Hygiene approach defines the key opportunities when health-care workers should perform hand hygiene as being: NHSL has reached an overall compliance level of 86% during 2016/2017 against the national compliance level of 95% or above. The organisation reached its highest overall levels of 90% and above in months November 2016 and January 2017 which is to be commended given the difficulties the organisation faced during winter pressures. Infection Prevention & Control Annual Report Page 11

12 Outbreak Management 73 separate outbreak situations managed in 2016/17 Outbreaks 21 Ward Closures 34 Monklands Hospital 19 Wishaw General Hospital 14 Hairmyres Hospital 6 H&SCPs 327 Bed days lost 305 Patients attended 134 staff affected Next Steps Completion of winter preparedness events across acute and H&SCPs Host training and educational events Engaging with staff to work proactively in managing patients / isolation / cohort to minimise effect Apply learning from Incident Management Team and / or Outbreak Management Debriefs Page 12 - Infection Prevention & Control Annual Report 2017

13 Carbapenemase-producing enterobacteriaceae (CPE) National Screening Programme Carbapenems are a class of very broad spectrum intravenous antibiotics which are reserved for serious infections or when other therapeutic options have failed. Extensive spread is now being experienced in a number of European countries with some countries moving to an endemic situation. CPE are a type of extremely antibiotic resistant bacteria. The Enterobacteriaceae are a family of Gram negative bacteria (sometimes called coliforms) which are part of the normal bacterial gut flora. They include common pathogens such as E. coli, Klebsiella sp, Proteus sp and Enterobacter spp. These organisms are some of the most common causes of many infections such as UTIs, intra-abdominal infections and bloodstream infections. Over the last year, NHSL have undertaken a pilot study within Monklands Hospital. This involved gathering key data in line with the number of patients requiring to be tested from the completion of a CRA. This information is being collated for wider roll-out to other sites in 2017 against the implementation plan. Vancomycin-resistant enterococci (VRE) Enterococci are generally of low pathogenicity and usually colonise rather than cause infection. They may cause serious illness in bloodstream infections, including endocarditis, and may be more serious in immunosuppressed patients. Control of the spread of VRE rests mainly in rigorous hand washing and environmental cleaning. Decolonisation is ineffective as these are normal faecal flora. VRE carriage is more common on haematology units. Exceedance in the number of VRE bacteraemias in Ward 16 at Monklands Hospital was experienced in NHSL in 2016/2017. As a result, the following phased interventions were initiated from July 2016 onwards leading to sustained reduction in number of HCAI VRE bacteraemia. Terminal clean and enhanced environmental regimes with Actichlor initiated. Targeted surveillance and patient screening. Enhanced antimicrobial stewardship Monitoring of patient placement and alert of Trakcare using Pink Star Increased presence of IPCT to monitor and support management of the situation. Infection Prevention & Control Annual Report Page 13

14 National Point Prevalence Survey 2016 HPS, on behalf of the Scottish Government, completed the third national prevalence survey of HCAIs and antimicrobial prescribing across Scotland in acute and non-acute hospitals in The survey was completed to take stock of the current burden of all HCAI types, the prevalence of antimicrobial prescribing and the types of antimicrobials being prescribed in Scottish hospitals. Prevalence surveys provide an epidemiological evidence base that will allow key priority areas for HCAI prevention interventions, incidence surveillance programmes and antimicrobial stewardship initiatives to be identified. The IPCT, Antimicrobial Pharmacist/Ward Pharmacists and acute site Consultant Microbiologists worked together during an intense 3 week period in October 2016 to complete all acute wards in Wishaw General Hospital, Hairmyres Hospital, Monklands Hospital, Ladyholme Hospital and Kello Hospital. From the hospitals surveyed there were a total of 70 wards included together with the completion of 1,326 patient surveys undertaken. The survey was completed in around 200 hours between IPCT, antimicrobial staff and the Consultant Microbiologists. Of the 1,326 surveyed there were a total of 35 patients with an active HCAI at that particular time which equates to 3% of our patients. Summary of NPPS Findings 3 : HAI remains a significant burden in Scotland; a greater burden than any other communicable disease. On average, there is one patient in every ward in every hospital at all times with HAI and there are an estimated 55,500 HAI each year in acute adult patients in Scottish hospitals. The patient population is older and sicker in comparison to five years ago and the most common HAI (UTI and pneumonia) reflect this population at risk. A quarter of blood stream infections (BSIs) were associated with a vascular cathether and half of UTIs occurred in patients who had been catheterised. Despite focused quality improvement work, the use of PVCs was higher in 2016 and there had been no change in the prevalence of urinary catheterisation since Antimicrobial resistance (AMR) remains a threat; antimicrobial prescribing was high and the types of HAI reported are commonly associated with Gram negative organisms where the greatest threat of AMR currently is E. coli, for the first time, was the most commonly reported causative organism. The use of very broad spectrum antimicrobials was unchanged from 2011, with the exception of piperacillin/tazobactam use in paediatric patients, there was potentially inappropriate prescribing of these antimicrobials as highlighted by those that were not in line with local policy. This survey highlights that the types of HAI occurring in Scottish hospitals are also associated with a large burden of prescribing to treat community acquired infections in hospital. Measures to reduce the risk of infection that can be applied to both community and hospital settings would reduce the risk of all infections in all care settings. 3 Health Protection Scotland. Scottish National Point Prevalence Survey of Healthcare Associated Infection and Antimicrobial Prescribing Health Protection Scotland 2017 [Report]. Based on the results from the NPPS, some priority areas for IPC quality improvement are: Development of multimodal national programme for prevention of pneumonia in non-ventilated patients; Development of a multimodal national programme for prevention of UTI in non-catheterised patients; Focus on prevention of sepsis and bloodstream infections in neonatal patients. Further focus on: Implementation of CAUTI prevention bundles for insertion and maintenance of urinary catheters in acute and community care Implementation of PVC and CVC insertion and maintenance bundles, with a focus on reviewing the requirement for continued use, to reduce the risk of BSI associated with vascular catheters. Improve availability of Alcohol Based Hand Rub (ABHR) at point of care in acute and non-acute care and the availability of data pertaining to ABHR Local IPCTs to ensure multimodal quality improvement strategies are in place for prevention of pneumonia (including pneumonia in non-ventilated patients), UTI (including UTI in non-catheterised patients), SSI and BSI care that are aligned with the WHO core components guidance. Continue to increase single room and isolation capacity. Page 14 - Infection Prevention & Control Annual Report 2017

15 Vale of Level Hospital Inquiry The organisation has been working towards fully implementing the 65 recommendations contained within the final Vale of Leven Hospital Inquiry Report. As at December 2016, the organisation reported to the LICC that 91% (59) of actions were fully compliant with 9% (6) of action mostly implemented. The progress to achieve the remaining actions continues into the next activity year reporting to the LICC at appropriate intervals. Training and Education IPCT Accreditation Members of the IPCT have been working hard to achieve accreditation in Infection Control. During this year, Linda Thomas and Kaileigh Begley achieved their MSc PG Dip Infection Control and Sandra Burke achieved her BSc in Nursing Infection Prevention and Control bringing the total number of Nurses accredited to Specialist level to 6.This is a significant improvement from previous position. NHS Lanarkshire The organisation has 12,300 staff members (clinical and non-clinical roles). Throughout 2016, 100 training and educational sessions were completed by the IPCT. The training topics consisted of: Topic specific Golden Hour (ward based training) Hand hygiene LanQIP Corporate Induction CAAS Launch (All Acute and Site Specific) Summer and Winter Roadshows Medical Induction HCA Course HSCW Induction NHSL Staff Learnpro Modules Completed 8953 Hand Hygiene 240 Principles of Aseptic Technique 143 HAI Clinical Induction Modules Complete 1196 Norovirus 553 MRSA Screening & Patient Management There are 6 key learnpro modules that new and existing staff members have access to complete. Hand Hygiene is mandatory for completion by staff and on a yearly basis. The other modules noted below are for completion as part of individuals personal development plans (PDP). 310 Clostridium difficile Infection Prevention & Control Annual Report Page 15

16 Lanarkshire Infection Control Committee (LICC) and Sub-Groups Lanarkshire Infection Control Committee (LICC) There have been 6 meetings held during the activity year. The annual work plan for the LICC was 95% complete at year end with the remaining actions carried forward the 2017/2018 work plan. Excellent progress been made over the last year in progressing the HCAI agenda for NHSL. The quality and presentation of documentation to the LICC has been improved. Lanarkshire Antimicrobial Infection Management Control Committee (AMC) (LICC) Quality: NHSL achieved Scottish Government reducing total antibiotic use national level 3 quality indicator for 2015/16. NHSL shared work at regional, national and international events: - Training: Implementing an antimicrobial stewardship and mentorship programme to encourage key nurse led antibiotic conversations. Federation of Infection Societies Annual Conference, November 2016, Edinburgh. - Assurance: Minimising patient harm from orthopaedic antimicrobial prophylaxis at a District General Hospital. United Kingdom Clinical Pharmacy Association Conference, November 2016, Manchester. - Safety: Improving the quality of antimicrobial prescribing sharing best practice on allergy awareness. Scottish Antimicrobial Prescribing Group National Networking Event, March 2017, Glasgow. - Stewardship: Oral Presentation Case studies on antimicrobial resistance for ward pharmacists European Association of Hospital Pharmacists Annual Conference March 2017, Cannes. Public Engagement: Antimicrobial guardian live sign up events and materials to promote public understanding and involvement. Winter Preparedness Roadshow Events, October 2016, various Lanarkshire Locality locations. Policy Review Group (PRG) NHSL has a responsibility to ensure arrangements are in place to warrant the continual health and safety of the population of Lanarkshire from the effects of infection or microbiological environmental hazards. The LICC and the Health Protection Committee (HPC) are the lead forums to oversee this area. The Policy Review Group (PRG) is a sub-group of the LICC and the HPC and is the strategic group responsible for ensuring the policies, guidelines and Standard Operating Procedures (SOPs) relating to IPC are updated and reviewed on a 2 yearly basis in line with the Standards for HCAI (2015). Page 16 - Infection Prevention & Control Annual Report 2017

17 Lanarkshire Infection Control Committee (LICC) and Sub-Groups Decontamination Environmental Management Group (DEMG) The DEMG was formed in April 2016, chaired by the IPC Doctor and first met in May The remit of the DEMG is to provide assurance to the organisation that NHSL have decontamination strategies in place to reduce HCAI acquisition as far as possible and to heighten awareness and provide guidance on important emerging decontamination issues locally. There have been 6 DEMG meetings held throughout The DEMG has a work plan in place which concentrates on key activities to support the implementation of Standard 8 Decontamination of the HCAI Standards This is reviewed and updated as appropriate to each DEMG meeting which provides a report to the LICC at each meeting of the progress that is being made. Water Safety Group (WSG) Over the activity year there have been 4 meetings held. There have been key pieces of work undertaken or completed by the WSG which included: The completion of legionella risk assessment programme ensuring all follow up actions as addressed. The completion of an internal water audit in NHSL owned or leased premises which flagged minor actions for local rectification and successfully undertaken. Improvements to the water log book system now electronic allowing water information to be updated immediately from site visits which will allow for faster turnaround of issues identified. Removal of humidifiers in operating theatres as deemed inefficient and detrimental with efficiency management. Humidifers removed from Hairmyres Hospital and the plant at Wishaw General Hospital has been disconnected. Hairmyres Hospital Hygiene Group Beckton Dickinson (BD) been supporting the site to improve Peripheral Venous Catheter (PVC) maintenance and insertion bundles in a bid to reduce number of PVC related SAB cases. A PVC driver diagram is in place to support this work. A mock inspection was carried out by IPCT in June A number of recommendations made for the site which has been taken forward with improvements made. Clinically Clean Month took place in November 2016, with a number of activities taking place across the hospital which included IPC related weekly themes in the Daily Onion newsletter and extended across the month; Big Bug quiz and prizes for the winners; One area per week targeted for an HEI inspection, with the ward with the highest scoring area each week receiving a prize. Results passed to the Senior Nurses for follow up of issues found. IPCT have supported golden hour sessions each week through November 2016, with Clinical Cleanliness CSI sessions being a particularly innovative and practical approach to engaging with staff. Infection Prevention & Control Annual Report Page 17

18 Lanarkshire Infection Control Committee (LICC) and Sub-Groups Monklands Hospital Hygiene Group Format and formality of the meetings has been reviewed, now more structured and effective. IPCT continue to be very supportive and we now have a base for the team. IPC issues are a large element of site safety huddles Due to focus of site group and LICC the site has received a significant investment for backlog maintenance leading to improvement in environmental standards. Bagging and tagging audits demonstrate good on-site working; site has gone from a poor performing site to one of the best. Wishaw General Hospital Hygiene Group The completion of two mock inspections on the 10 October 2016 and 1 December 2016 which were extremely worthwhile, well received in terms of the approach together with the key learning and improvements identified from the findings. The inspection process will continue into Working closely with colleagues from other sites in supporting one another in completion peer reviews of our environments. There has been improvement in LanQIP access which now allows the clinical areas / departments to upload their monitoring programme results to support local improvement programmes. There has been significant work undertaken in conjunction with BD in identifying key areas for improvement with regard to PVC insertion and maintenance bundle compliance which is being taken forward locally and reported to the Hygiene Groups and LICC. Health & Social Care Partnerships Hygiene Group HSCP Hygiene Groups were set up in 2016 with the Terms of Reference and membership agreed. The group meetings are held monthly. Continues to develop and refine auditing and reporting processes including identification of all clinical environments to be logged on LanQIP. Standard Infection Control Precaution audit topics and frequency relevant to individual clinical services was agreed. Page 18 - Infection Prevention & Control Annual Report 2017