Shetland NHS Board. Control of Infection Committee Annual Report

Transcription

1 Shetland NHS Board Control of Infection Committee Annual Report April 20- March

2 Acronyms and Abbreviations ARI AOBD CDU CoIC CSBS HAI HAI SCRIBE HDL HEAT targets HPS ICT NES MMR PFPI PPE MRSA MSSA QIS SAB SIGN SHOR SPSP SSHAIP SSIS Aberdeen Royal Infirmary acute occupied bed days Central Decontamination Unit Control of Infection Committee Clinical Standards Board for Scotland Healthcare associated infection Healthcare Associated Infection System for Controlling Risk in the Built Environment Health Department Letter Health, Efficiency, Access, Treatment Targets Health Protection Scotland Infection Control Team NHS Education Scotland Combined measles, mumps and rubella vaccination Patient Focus Public Involvement Personal Protective Equipment Meticillin Resistant Staphylococcus Aureus Meticillin Sensitive Staphylococcus Aureus Quality Improvement Scotland (previously CSBS) Staphylococcus Aureus Bactereamia Scottish Intercollegiate Guideline Network Scottish HAI Outbreak Online Reporting System Scottish Patient Safety Programme Scottish Surveillance of Healthcare Associated Infection Programme Surgical Site Infection Surveillance 2

3 Contents 1 Introduction 4 2 Background to Work Programme 7 3 Progress against Work Programme for Other activities 18 5 Patient Focus Public Involvement 20 6 Occupational Health 20 7 Communicable Disease Control 20 8 Significant Incidents 22 9 References 23 Appendices Appendix A: Communicable Disease & Infection Control Surveillance Report Appendix B: Work Programme for Appendix C: HAI Annual Report

4 1 Introduction Infection control covers a wide range of activities. These range from preventing patients picking up infections when they come into hospital, to controlling outbreaks of infectious diseases, such as food poisoning, in the community. Although much activity is coordinated by the Infection Control Team (ICT) led by the Director of Public Health, key responsibilities are held by the infection Control Manager (the Board s Director of Nursing), and many others are involved in infection control activities. These include NHS clinical staff, cleaning staff and the Estates Department and the Shetland Islands Council s Environmental Health Department. The Control of Infection Committee (CoIC) acts as the central committee to oversee all infection control issues within Shetland NHS Board. In 2007 the constitution of the Committee was revised to bring it up to date with new roles and responsibilities within the Board, and the membership and remit of the Infection Control Team was similarly reviewed. 1.1 Remit of committee To review and provide advice on Shetland wide infection control strategies and policies within the service To facilitate collaboration and co-ordination between different health service sectors, Shetland Islands Council and other agencies and to liaise with neighbouring NHS Board Control of Infection Committees To provide advice and support to the ICT and to assist the Director of Public Health in providing advice to hospital and community services To endorse the annual infection control programme prepared by the ICT To prepare an annual report for the Board, presented through risk management and clinical governance channels to the Clinical Governance Committee 1.2 Accountability The Control of Infection Committee reports regularly (and also in the event of a significant incident or outbreak) via the Clinical Governance Coordinating Group and Health and Safety Committee to the Clinical Governance Committee. The Clinical Governance Committee is the Board appointed Committee for health and safety and clinical governance matters in NHS Shetland. The Control of Infection Committee receives reports from the Control of Infection Team, and also a direct report in the event of a significant incident relating to infection control, or outbreak. 4

5 Shetland NHS Board Clinical Governance Committee (Risk Management) Health and Safety Committee Annual Report Clinical Governance Coordinating Group Control of Infection Committee Vacc & Imm Group Infection Control Manager Infection Control Team Cleanliness Champions 5

6 1.3 Committee membership April 20 March 2009 Director of Public Health Sarah Taylor* Consultant in Public Health (Deputy for DPH) CDU Manager / Infection Control Nurse (Hospital) Infection Control Manager Public Health Nurse CHP representative / Asst. Director of Nursing (Community) Asst. Director of Nursing (Hospital) Consultant Microbiologist Estates Manager Susan Laidlaw* Carol Colligan* Nina Fraser* Wendy Hatrick* Edna Mary Watson* Janice McMahon* Tom Reid (based in Aberdeen) George Keith (acting) Laboratory service rep Pam Ivens to January 2009 Les Phipps from January 2009 Occupational Health Nurse Pharmacy Manager Medical Director or rep Cleanliness Champion rep Sodexho Hotel Services Manager or rep NHS Grampian Infection Control Manager SIC Environmental Health Services Manager General Services Co-ordinator Area Medical Committee rep Lay Representative Trudy Barnes* David Anderson Ken Graham Edna Peterson Ailsa Clews John McKinnon Maggie Dunne Magnus Flaws Vacant Hazel Gray * member of Infection Control Team 6

7 2 Background to Work Programme The work programme covers a number of areas concerned with infection control both in health care settings and the community. These include: surveillance training policy and procedure development prevention and management of healthcare associated infection audit. As in previous years, most of the work programme for was based on developing and implementing local action plans concerned with the prevention and management of healthcare associated infection (HAI), a national priority for the Scottish Government. There are three main areas within this priority (infection control including hand hygiene, decontamination and hospital cleaning) and each is subject to national standards and recommendations. Infection Control NHS Quality Improvement Scotland (QIS)* HAI Standards 1 Watt Group Report (2002 following Salmonella outbreak in a Glasgow hospital) 2 HDL (2005) 7 Infection Control and Cleaning: Nursing Issues 3 HDL (2005) 8 Infection Control: Organisational issues 4 NHS Scotland Code of Practice for the local management of hygiene and healthcare associated infection 5. Decontamination NHS Quality Improvement Scotland (QIS) HAI Standards 1 The Glennie Framework (2001) further standards for decontamination 6 Further guidance on primary care compliance with decontamination standards Hospital Cleaning NHS Quality Improvement Scotland (QIS) HAI Standards 1 The NHS Scotland National Cleaning Services Specification (published in 2004 by the Healthcare Associated Infection Task Force) 7 National Cleaning Services Specification Monitoring Framework 8 *previously Clinical Standards Board for Scotland (CSBS) 7

8 2.1 HAI Taskforce Delivery Plan In 2003, the Scottish Executive Healthcare Associated Infection Taskforce was set up in response to the response to the Ministerial Action Plan Preventing infections acquired while receiving healthcare. 9 The Taskforce produced a programme of work which aimed to co-ordinate and build on existing HAI activities across healthcare settings in Scotland, based on the message: 'clean healthcare environments, clean hands, clean instruments'. In 2006 the Taskforce published a Delivery Plan for , which includes further work on the areas listed above, along with new initiatives such as the National Hand Hygiene Campaign. The table below lists some of the key areas for the Delivery Plan along with examples of actions that have required continuing local work at Board level during Delivery Areas Hand hygiene Implementation and performance Education Examples of actions requiring local work Local implementation of Hand Hygiene Campaign HEAT target To reduce all Staphylococcus aureus bacteraemias (including MRSA) by 30% by Implementation of organisational structures including role of Infection Control Manager Cleanliness Champions programme Development and launch of HAI education programmes including hand hygiene training Surveillance National HAI Prevalence Survey (2007) Public Involvement HAI Task Force documents Patient safety Cleaning and hygiene Estates, facilities and environment Specific organisms Introduction of national SAB surveillance forms (20) Handling of patient / public feedback Public involvement in monitoring compliance with National Cleaning Specification Support implementation of national public information strategy & awareness raising Implementation of model policies for infection control Guidance on links with community based healthcare, including care homes HAI incident and near miss reporting Use of risk matrix for HAI Implementation of monitoring framework for NHSScotland National Cleaning Services Specification Implementation of HAI Scribe Risk Control System Infection Control in the Built Environment: Design & Planning for Scottish Healthcare Facilities Mandatory surveillance of Clostridium difficile, MRSA & MSSA 8

9 All these actions are being implemented in NHS Shetland through the CoIC Work programme. Further guidance and recommendations from the HAI taskforce will be incorporated into next year s Work Plan ( ) as they are disseminated. Other work planned by the HAI Taskforce includes development of a national MRSA Control Strategy and development of more education programmes, including antimicrobial prescribing. 2.2 HAI Action Plan (in response to Vale of Leven C diff outbreak) In 20 there was an outbreak of Clostridium difficile at the Vale of Leven Hospital in NHS Greater Glasgow and Clyde. 55 patients developed CDAD and 18 died. As a result of this there was an Independent Review and a number of issues were identified that contributed to the problems at Vale of Leven. The Scottish Government subsequently produced a HAI Action Plan to address these issues and ensure good infection prevention and control procedures are in place across all NHS Boards. These actions were built into the CoIC Work plan for 20-09, and nearly all were completed by the end of March Further detail can be found in Section 4. The actions relate to: Governance Charge Nurse Leadership Facilities Hand Hygiene Finance Public Information Antimicrobials Scottish Patient Safety Programme Policies and Procedures Infection Control Service Death Certification Surveillance Clinical Governance and risk management Communication HAI Standards Education and Training NHS Scotland Dress Code and Uniform Policy Cleanliness Champions Environmental Cleanliness Professional Development 9

10 2.3 NEW QIS Standards In March 20 QIS published new HAI Standards for local assessment, and key actions in relation to these were included in the work programme for These standards focus on compliance, patient focus and public involvement, prevention and control of infection, environment and equipment, and education. Their aim is to build on the previous HAI standards, which focussed on structure and processes, and now to focus on outcome measures that will demonstrate improved Board performance. They recognise the importance of the NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Acquired Infection in the development of these standards, to build on work already implemented by the service. The new standards have been written to emphasise that all staff need to be involved in infection control initiatives, and to reinforce the role of infection control staff in providing expert knowledge and guidance to enable all staff to contribute to the overall aim of reducing healthcare acquired infection. The detail of continuing to work towards compliance with the standards is included in the work programme for 2009/10. All NHS Boards are also required to complete a selfassessment against the QIS Standards by June Progress against Work Programme for Surveillance Surveillance is the collection and analysis of information about cases of illness, for example infectious diseases. It is used to understand patterns of illness, particularly to pick up where there is an unexpected increase in the number of cases of a disease. The Committee receives regular surveillance reports on MRSA; Surgical Site Infection Surveillance; sharps injuries amongst NHS staff, notifiable diseases and vaccination uptake rates. Reporting on Clostridium difficile was introduced in 2006 (in line with the national surveillance programme), as well as reporting on all Staphylococcus aureus bacteraemias ie to include MSSA. The Annual Surveillance Report (Appendix A) contains further details of the items summarised below MRSA (Meticillin Resistant Staphylococcus Aureus) MRSA is a bacteria carried by many people that can sometimes cause serious infections, particularly in hospital patients. MRSA is identified in two ways: Screening of high risk patients (eg those transferred from a mainland hospital) Isolating MRSA as a cause of infection (for example a wound swab or urine test) All patients transferred from hospitals on the Scottish / UK mainland to the Gilbert Bain Hospital or Montfield are routinely screened for MRSA. All other patients are risk assessed, and screened if deemed to be at higher risk of MRSA (for example those with previous MRSA or recently discharged from mainland hospital). In Shetland, the Public Health Department collects information on colonisation and all infections caused by MRSA and reports these to the Control of Infection Committee. We 10

11 also take part in the national surveillance system for MRSA bacteraemia (a serious blood infection caused by MRSA). In January 2009, Public Health introduced a new surveillance form for MRSA and MSSA bacteraemias, the national Staphylococcus Aureus Bacteraemia SAB form; and in March 2009, we introduced a new local surveillance form for all other MRSA infections (adapted from the SAB form for local use). Whenever Public Health receives notification of a new case of SAB or MRSA infection, the referring ward or GP practice is asked to complete a surveillance form. These new forms allow the Public Health team, and the ward or primary care teams, to identify and investigate if there were risk factors present and if there was anything that could have been done differently to prevent the infection. The national system reports cases of MRSA bacteraemia with control limits designed to show where variations in rates might be significant. The MRSA bacteraemia rate for the whole of Scotland has remained stable since the surveillance system was first introduced in During 20-09, there were no cases of MRSA bacteraemia in Shetland. The small number of episodes reported from Shetland mean that these numbers should be interpreted with due caution, and no conclusions about trends can be drawn. The biggest risk to maintaining the local rate is seen to be the importing of infections with patients travelling back to Shetland from mainland hospitals. At present there are strict controls in place for screening and isolation of incoming patients, and these will continue, though pressure on beds with more challenging waiting times targets and local redesign of services will need to be countered with continued and additional vigilance and contingency management. In 2006, reporting of all Staphylococcus aureus bacteraemias became mandatory, ie both MRSA and meticillin sensitive Staphylococcus aureus. (MSSA). A HEAT target has been introduced for Boards to reduce all Staphylococcus aureaus bacteraemias by 30% by In Shetland this was on a baseline of 1 case per quarter. As reported above, the numbers of cases reported in Shetland is low, and very small variations in numbers one or two cases, can change the rate disproportionately. In there were 4 cases of MSSA bacteraemia Clostridium difficile The national surveillance programme monitors the occurrence of Clostridium difficile associated disease (CDAD) in all patients aged 65 and over presenting with diarrhoea who have been in contact with the healthcare system. Cases are identified through laboratory reports (Shetland samples are tested in Aberdeen). The programme commenced in October The first national Annual Report of the system was published in December 2007 and it provided reference baseline data for NHS Boards in Scotland. In Shetland it showed an annual rate per 100,000 inhabitants over 65 of 421, against a national average of 656. The local figure as a rate per total occupied bed days for care of the elderly beds was 0.77 (national average 1.27) and for acute hospital beds was 2.10 (national average 2.03) a difference that is not significant given the small numbers locally. The 20 report showed that the rate of C.diff per AOBD in Shetland was 0.42 and the national rate was 1.29 for all patients over 65. There is now routine testing for Clostridium difficile on all faecal samples from people age 15 and over. 11

12 The Public Health team introduced a new local surveillance for CDAD in January This is based on the SAB forms described above. As with the SAB surveillance, these forms allow closer investigation of risk factors for Clostridium difficile. Quarterly reports are produced on a national basis, and the quarterly figures are shown in Appendix A Surgical Site Infection Surveillance (SSIS) Surgical site infections are one of the most common healthcare associated infections, resulting in an average additional hospital stay of 6.5 days and an additional cost of over The national surveillance scheme has been running since In Shetland, information is collected on two surgical procedures: fractured neck of femur (broken hip) and emergency caesarean section. Initially information was collected only up until the time of discharge, but since October 2006, information has been collected up to 30 days post-operatively. Since January 2007 it has been a national requirement to collect information up to 30 days for orthopaedic procedures and caesarean sections. However, the mandatory follow up for caesarean sections is due to revert back to 10 days in April The local data shows that we have a small number of procedures and a small number of infections, with no significant trends to date (see Appendix A). A range of measures have been introduced to reduce these infections, which are detailed in the section on Healthcare Associated Infection Communicable disease surveillance The Public Health Department is informed of all cases of notifiable disease confirmed by the laboratory and a large number of clinical cases identified by GPs and hospital doctors. This information is forwarded to Health Protection Scotland, which produces weekly updates on a national basis. Appendix A shows these figures in detail for 20-09, along with commentary on some of the specific infections reported Vaccination uptake rates Childhood immunisations are managed and monitored through a local Vaccination & Immunisation Group, which reports regularly to the Control of Infection Committee. National uptake figures, broken down by NHS Board and CHP, are reported on a quarterly basis by National Services Scotland Information and Statistics Division (ISD). The Vaccination & Immunisation Group uses these reports to monitor trends and take action if necessary. The Immunisation Co-ordinator also receives uptake figures broken down by GP practice and feeds these back to individual practices. Details of uptake are included in Appendix A Sharps injury A sharps or contamination injury is when someone receives a puncture wound from a needle or other sharp instrument or object which could be contaminated and which may lead to infection. Also a person could come into contact with blood or body fluid that is blood stained through splashes in the eyes, mouth or broken skin or through a bite from a person. Although rare, there is the risk of contracting a blood borne infection such as HIV, Hepatitis B or Hepatitis C through a sharps or contamination injury. 12

13 According to the National Institute of Safety and Occupational Health in the average hospital, workers incur approximately 30 reported needlestick injuries per 100. The local rate of reported sharps injuries is on average, 3 to 4 per quarter for 559 Staff. Therefore this indicates that Shetland NHS statistics of sharps injuries have reduced from last year. Efforts have continued over the last year to increase awareness and training on sharps and blood borne viruses. There has been formal training in 20 through the Staff Development Service, and this will continue to be planned for On pre employment Staff are given individual advice on sharps injury management. The new intake of Doctors will also be targeted in August 2009 and thereafter on an individual basis on pre employment There is a sense that reporting of injuries has improved. The revised policy has been agreed on Occupational exposure to blood borne viruses and the accompanying procedures have been consulted on widely with staff and amended in the light of staff feedback and experience. The Occupational Health department continues to play a significant role in both raising awareness and training, and in responding to incidents. Incidents are logged and Clinical areas that have had more than one incident have reduced by targeting them with additional support. 3.2 Training Decontamination: Central Decontamination Unit (CDU) staff: A third CDU Operator completed the NVQ at Level 3 in Decontamination and a fourth has started the NVQ. Another operator completed the Assessors course to allow them to assess the NVQ. One member of staff has completed the Cleanliness Champions Course. The CDU Manager has completed eight modules on the MSc in Medical Device Decontamination, and is now at Postgraduate Diploma level. She will be doing her dissertation in the coming year to complete the MSc Induction & refresher days for all NHS staff The Corporate induction day now in its seventh year has continually developed and continues to be delivered to all staff, except the junior doctors and Student nurses, as both of these groups have their own specific induction. The induction day has a number of specific session, delivered by experts, that the Board has decided are essential for all new staff to be made aware of and control of infection is such a topic. The first Monday of every month, when induction is delivered, requires a member of the infection control team to give a 15-minute presentation on infection control. This session is usually delivered by either the Director of Public Health or the Public Health Consultant. This indicates the importance to the new members of staff of infection control. Between April 20 and March 2009, 98 new members of staff attended the induction session. Mandatory Refresher Training also runs every month and it is expected that every staff member, including bank staff, attend this course. The course is reviewed and revised every 18 months and in this cycle there are a number of areas where infection control training is delivered. Firstly this day is split into two distinct parts; a morning where sessions are delivered in either presentation or practical session. The second part is for delegates to complete some Learn Pro e-learning modules. There is a practical session on infection control, which can be varied according to the needs of the staff attending, but generally involves an update on current issues and new 13

14 procedures and also the opportunity to use the UV light box to check hand-washing technique. Again this session is usually delivered by a senior member of the Public Health Team. Evaluation of this session is consistently good. Between April 20 and March 2009, 153 delegates completed this training. One of the Learn Pro modules that delegates are required to completed is on Health Care Associated Infection. So far 189 staff have completed this training including both clinical and non-clinical staff. There is an additional module for clinical staff on food hygiene: 148 have completed this module. Finally the optional module on safe transfusion has been completed by 137 staff. The student nurse induction has been updated and now includes a more comprehensive session on control of infection. This involves hand washing techniques and the proper use of gel dispensers. Training has taken place with Health Care Support workers and a series of courses has been developed to develop the skills of this group of staff. A session on HAI has been included and delivered to 12 delegates IV drug infusion training This training is offered to all staff involved in the administration of IV infusion drugs. There is specific input related to risks of infection and infection control. Six staff were trained in Cleanliness Champions (NHS Education Scotland package) 159 staff are registered on the Cleanliness Champions course and 58 have completed the course. All nurses and AHPs now have the cleanliness champions courses within their personal development plan Food handling training for ward staff There is a module on the Learn Pro package that all clinical staff must complete on food hygiene, as stated previously 148 staff members have completed this module Other training: Accident and Emergency staff Decontamination training run by the SORT team of Scottish Ambulance Service is to be run in April 2009 for all A&E staff. Further training will be required if and when a new decontamination unit is installed. Embedding Infection control issues into all training In the previous report figures were listed for courses that were primarily concerned with infection control. Over the past 12 months the Board has tried to mainstream and embed infection control issues into all clinical training courses. This has resulted in gel pumps being installed into all training rooms and courses such as moving and handling (391 delegates attended), basic life support (197 delegates attended), immediate life support (45 delegates attended), catheterisation (18 delegates attended), venepuncture (10 delegates attended), Resus Skills (14 delegates attended) Paediatric life support (30 delegates attended), Dental PLS (34 delegates attended) involve scenarios where staff must use the dispensers appropriately to be successful. Indeed, even on the management development course having difficult conversations there is a scenario 14

15 around a staff member not washing their hands for managers to consider and take necessary action. The Mobile Skills Unit visited Shetland and one of the clinical training sessions, which was recorded on video, involved the use of gel and hand washing as a core element of this training. The Board, through the Staff Development Unit will continue to adopt this approach to ensure that infection control is a key element of all the training offered to Shetland NHS Board Staff and becomes embedded in day to day practice. Staff Development Bulletin There is a new Infection Control section in the Staff Development Bulletin, which highlights key issues and training opportunities for all staff. It also contains a list of useful websites so that staff can access infection control information and training electronically and at a time that suits Infection Control Team: individual training programmes Members of the Infection Control Team have also undertaken specific training within their Personal Development Plans. 3.3 Policy and Procedure Development Communicable disease / public health incident plans and procedures The following policies, procedures and plans were approved by the Control of Infection Committee during Procedures for the management of MRSA Procedures for the Management of Clostridium difficile Procedures for the cleaning of care equipment Procedures for management of blood and other body fluid spillages Environmental cleaning procedures Patient placement procedures Revised procedures for protection against occupational infection with blood borne viruses Pandemic Flu Contingency Plan ver 4.0 (April and November 20) Legionella Health and Safety Policy A number of other procedures and plans are due to be completed during the first half of 2009/10: TB Policy and procedures Procedures for the safe management of Linen Public Health Incident / Outbreak Plan, incorporating Hospital Outbreak Plan Further revision of Pandemic Flu Plan in line with national guidance 15

16 3.4 Prevention of Healthcare Associated Infection (HAI) Infection control standards Cleanliness Champions The local Cleanliness Champions continue to take forward the programme of local work on the prevention of Healthcare Associated Infection, with a particular focus on hand hygiene during the past year. Whilst there are over 150 staff registered only the course, only 58 have completed and there will be work in the coming year to ensure that staff can completed this training. There is now a Board requirement that all qualified nurses and allied health professionals undertake this training, but all staff are encouraged to consider doing the course. There has also been interest from colleagues in social and community care Hospital cleaning The National Cleaning Services Specification is included in the Board s contract with Sodexho to provide cleaning services and this is monitored regularly. A representative from Sodexho is now included as a member of the Control of Infection Committee and the Board s Facilities Manager reports regularly on the monitoring information. The figures for compliance have achieved between 95.2 and 98.5% throughout An independent audit was carried out in 20 and the improvement recommendations have all been carried out Decontamination All equipment from General practitioners is now processed in the Gilbert Bain Hospital Central Decontamination Unit (CDU). Centralisation of decontamination for Podiatry commenced in August 20. The dental workload has been examined and appraisal of the possible options for how best to provide decontamination to meet the national requirements for compliant facilities by the end of 2009 is now underway. The upgraded dental surgeries in the GBH opened in August 20 with all instruments from these surgeries to be processed in CDU. CDU was externally audited by an external company, TÜV Product Services, in September for the annual re-accreditation of the Unit Surgical Site Infection Surveillance The surgical team collects surgical wound infections data on a continuous basis. Data are presented at the monthly surgical audit meeting to discuss individual cases and any emerging patterns or trends to surgical site infections. A small team has been formed in Theatre to ensure returns are completed for the thirty days Surgical Site Surveillance for Caesarian Sections and Fractured Neck of Femurs. Surgical site infections have been reduced to zero in the second category since surgical wound drains have been inserted at the time of operation preventing infection of any haematomas occurring. There has been a marked improvement in the data returned to HPS since this team has come into operation and they are available to provide any extra advice required by staff. The surgical team have started to work with some of the pre-operative care bundles as part of the wider Patient Safety programme. The focus of the patient safety programme in 16

17 20-09 was to implement a range of measures relating to the reduction in HAIs and this included introducing extra checks for peripheral cannula management, central line management and hand hygiene and improvements have been noted in these areas. Further work on pre-operative topics will be considered in the coming year Hand Hygiene Campaign From April 2007 onwards, NHS Shetland has participated in the national hand hygiene campaign, with the appointment of a Local Health Board Co-ordinator (LHBC) who has led awareness and training, and conducted the local audits on hand hygiene within the national programme. These have been reported regularly into the Control of Infection Committee. Figures for 20 and 2009 are shown below. The audit focussed on compliance with hand washing through observations of hand hygiene opportunities and testing the knowledge of staff through a survey asking key questions about local hand hygiene procedures. Audit was done quarterly until December 20 and is now undertaken monthly. May 20 August 20 Nov Dec 20 Jan 2009 February 2009 March 2009 Compliance 79% 89% 95% 89% 99% 94% Number of observations The Hand Hygiene Co-ordinator has been active in promoting good hand hygiene amongst staff, patients and visitors, including advising on the siting of alcohol gel dispensers and other hand hygiene facilities. The national campaign was effectively relaunched in March 2009 with new posters, leaflets and other resources. These are now prominently displayed in the Lerwick Hospitals. 3.5 Audit The main areas of audit work have been the Hand Hygiene audits carried out monthly by the Hand Hygiene Co-ordinator and the Cleaning Specification audits. A number of audits in relation to infection control were included in the Board s Audit work programme for 20/09 but only one was completed, Use of Personal Protective Equipment (PPE) was carried out in the two wards at Montfield both showed 100% compliance. MRSA Management in the Community and Hand Hygiene and the Use of PPE of PPE in Primary Care did not proceed past the planning stage. HAI SCIBE audits have been carried out in almost every clinical area in NHS Shetland, except two of the non-doctor island clinics. Now that nearly all the new Infection control procedures have been disseminated, we will be able to introduce audit against these procedures during

18 4 Other activities 4.1 HAI Action Plan (Vale of Leven) We have clarified the local roles and responsibilities related to HAI Progress, including surveillance reports and results of cleaning and hand hygiene audits are now reported to Board Meetings on a 2 monthly basis and also published on the Scottish Government website. Work on empowering Charge Nurses to deliver against their responsibilities and implementation of the recommendations of the Senior Charge Nurse review HAI SCIBE (Healthcare associated Infection System for Controlling Risk in the Built Environment) audits were undertaken both for all planned projects (including maternity, new IPU, endoscope washer room and day surgery) and all clinical areas in NHS Shetland (except 2 non doctor island clinics which are due to be done in the first quarter of 2009/10). This was an extensive piece of work involving the Estates Department, Infection Control Team, Capital Projects Manager and Director of Service Improvement along with representative from every area audited. The audits have resulted in a very long action plan covering every piece of work that should be undertaken to achieve full compliance with the healthcare facilities guidance. The actions have been prioritised and built into the Estates and Capital Projects work plans for 2009/10 and beyond. There has been considerable work with the Estates Improvement Team to ensure that planned preventative maintenance programmes and procedures reflect infection control requirements The Hand Hygiene Programme has continued, and the Board now has a zero tolerance approach. All patients admitted to hospital electively now receive information on HAI. And further information on a range of topics is available on the wards and the Board website. The Board has been following the Grampian Antimicrobial Prescribing Policy whilst a local Policy is being developed with support from a specialist pharmacist from Orkney. Antimicrobial Prescribing The NHS Shetland Antimicrobial Management Team (AMT) is being established in April A key role for the AMT is the development, implementation and compliance monitoring of a local antimicrobial policy which includes restrictions on the use of broad spectrum antibiotics, particularly those associated with C.difficile disease. The work plan for the AMT for the coming year includes the development of an empirical antimicrobial guideline, reviewing and amending the surgical antibiotic prophylaxis protocol, where necessary, in light of the publication of SIGN 104 and collecting data on the three prescribing indicators that support the HEAT target for Clostridium difficile associated disease. NHS Shetland is also participating in the European Surveillance of Antimicrobial Consumption Point Prevalence Study (ESAC-PPS) in June 2009 and the data 18

19 collected will provide information about the use of antimicrobials locally. It will also contribute to the wider picture on the prevalence of use of antimicrobials both in Scottish hospitals and across Europe. The elements of the Scottish Patient Safety Programme related to Infection Control are being implemented including use of care bundles and reporting of HAIs. There has been an extensive programme of policy and procedure development in the past year, and the final procedures are due to be completed early next year. The Board is using the tools developed by HPS to investigated severe CDAD when appropriate. Although the Board procedures are applicable to both secondary and primary / community care, there will be further work next year to implement procedures within primary and community care, including implementation of the new guidance due to be produced by Health Protection Scotland. The Infection Control Team responsibilities and function has been reviewed, resulting in the development of a new Infection Control Nurse post which is for one year in the first instance (includes some maternity leave cover) Guidance on completing death certificates has been produced and will be approved by the CoIC early in 2009/10 Surveillance processes have been revised to incorporate relevant actions for the action plan. HAI risks on the Board s Risk Register have been reviewed and a more detailed list of risks is to be compiled by the Infection Control Team focusing on operational aspects. Self-assessment against the QIS HAI standards will be undertaken in June In preparation, the Board s external auditor was asked to complete an initial audit against the standards in the first quarter of The CoIC Training Plan has been reviewed to ensure all staff receive the appropriate levels of infection control training applicable to their role. All staff have HAI training included in their PDP (i.e. induction and mandatory refresher training) The local Uniform Policy has been revised to ensure compliance with CEL 53 (20). The cleanliness champion s programme continues as above. Nursing staff check the standard of cleaning in their own areas and sign off to ensure it is reaching required standards. The cleaning schedules and standards attained are being publicised in clinical areas. 4.2 Scottish Patient Safety Programme (SPSP) The Ventilation Acquired Pneumonia (VAP) Prevention Bundle, Central Line Insertion Bundle and the Central Line Maintenance Bundle are all critical care procedures and they are being taken forward by the Consultant Anaesthetists. Current practice is already in keeping with these best practice protocols and the SPSP Lead for Critical Care is 19

20 reviewing existing procedures against the patient safety guidance. A checklist for CVP line insertion that demonstrates compliance with best practice and the SPSP bundle has been introduced but this has not yet been audited. Central line blood stream infection rates is one of the measures being reported by Critical Care: there has been one in the past year. Cannula management practice is being reviewed on Ward 1, Ward 3 and HDU. 5 Patient Focus Public Involvement Public membership of the Infection Control Committee was achieved in 2007 through a nomination made to ShetlandNHS100, and there is lay involvement in the Hospital Cleaning Services monitoring. Presentations on infection control issues have been made to NHS100 and to other bodies and interested parties on request. Attendance at a Community Council to discuss healthcare associated infection took place in 20. Healthcare Associated Infection and specifically Hand Hygiene activity has been a continued focus for the Patient Focus Public Involvement (PFPI) Steering Group, and one of the priorities identified for the Board s PFPI work programme. Feedback from NHS100 has continued to directly influence details of local campaigns, and members of the public and patients continue to be involved in the production and review of written materials for patients and the public, and in local assessment against national service standards, which are reported via the Board s assessment by the Scottish Health Council. Direct feedback from the public about hand hygiene in the hospital has been very positive, and a change in behaviour amongst visitors to the hospital has been noticeable. 6 Occupational Health The Occupational Health Department now has a full compliment of staff and has been actively contributing to the work of the Control of Infection Committee and Infection Control Team. The OH staff are particularly involved in management, monitoring and training regarding sharps injuries. They have also been involved in the development of local policies and procedures, particularly the TB Policy. 7 Communicable Disease Control The Public Health Department has an ongoing responsibility for communicable (infectious) disease control in the hospital and the community. Over the past year, it has continued to deal with communicable diseases notified to the department; offering advice and instituting control measures where necessary, often in conjunction with Environmental Health. Staff have been involved in a range of activities including: Direct contact with and liaison between patients, the public, NHS staff, environmental health and others Dissemination of information including to patients, the public, NHS staff and the media Further development of departmental systems for surveillance and management of communicable diseases and related issues using computerised recording of cases and incidents. 20

21 Delivery of training, both to NHS staff through the induction and refresher days and to other partner organisations, eg care homes, on request. 7.1 Vaccination & Immunisation Group The Board s Vaccination and Immunisation Group meets regularly and reports to the Control of Infection Committee on uptake rates, and on local actions to improve uptake and comply with national policy. In 20/09 the main area of work has been the introduction of the new Human Papilloma Virus (HPV) immunisation programme for the prevention of cervical cancer, which started in September 20. This work included training for staff, awareness raising and publicity (particularly with hard to reach groups) and delivering the programme in schools and child health clinics. Provisional uptake figures show that just over 90% of eligible girls in school received the vaccine. The Immunisation Co-ordinator has been actively involved in promoting the on-line Immunisation Training Package, four staff have completed the course and a further five are actively engaged with it at present. Four local Immunisation Update Training sessions were run in These were evaluated as being very successful and they will continue to run on an annual basis. Other work includes revision of local consent and recording forms, which should be completed next year. Details of local surveillance and uptake figures are included in Appendix A. 7.2 Emergency Planning The DPH is a member of the Shetland Emergency Planning Forum. The Forum meets at least annually and considers all types of local emergency including incidents that may affect the health of the public such as infectious disease outbreaks and biochemical hazards. The DPH, along with the Assistant Director of Nursing (Hospital), is also a member of the Forum Executive, which meets quarterly. An Emergency Planning Annual Report is produced annually and presented to Shetland NHS Board. The Board has continued to make progress on the development of Business Continuity planning, with a review of plans within core services, and latterly, updating in the context of pandemic flu preparedness. In March 20 a table top training exercise was held at Gilbert Bain Hospital to test procedures for an outbreak of infectious disease within the hospital. This led to the development of flow charts to assist mangers and nursing staff in identifying an outbreak and the feedback will also inform the local Public Health Outbreak / Incident Plan which is due to be completed next year. 7.3 Pandemic Flu Planning The local Pandemic Flu Co-ordinator has been attending the national co-ordinators meetings with the Scottish Government Team either in person or by videoconference. As noted above, the local Pandemic Flu Plan has been revised throughout the year to take into account national guidance, specifically the Scottish framework for responding to an influenza pandemic published in October A table top exercise was run in November 20 specifically aimed at primary care and community care staff to look at 21

22 their planning and responses to a pandemic. Sixteen people attended this exercise, from both NHS Shetland and Shetland Islands Council attended, including some medical students and a member of the Scottish Government Pandemic Flu Team. 8 Significant Incidents Significant incidents involving infection control matters are reported regularly to the Control of Infection Committee. Complaints would also be reported, but no complaints on Communicable Disease matters have been received. Four significant incidents have been logged during the past year: Blue-green algae was detected at the Loch of Cliff in Unst in July 20. Appropriate measures were taken by Environmental Health and Public Health, following the local Blue-green Algae Plan. There was no evidence of human illness as a result of the algal bloom. Water supplies at Montfield. A dead bird was found in one of the water tanks at he hospital in September 20. The appropriate measures were taken including supplying bottled water for drinking, testing the water supplies for contamination, flushing out the system and changing the water supply to mains to prevent this happening again. There was no evidence of any adverse health effects. Bed spacing in new Ronas Ward. Following the report into the C.diff outbreak at the Vale of Leven Hospital, the local Hospital Capital Plans were reviewed, specifically with respect to bed spacing in the new Ronas ward. The Board agreed to change the Capital plan with changes to the bed spacing to ensure compliance with national guidance. The DPH produced an action plan to ensure that Capital Plans in the future are compliant. In November 20, there was an incident where a patient was admitted to hospital and the admitting ward was not informed of the patient s MRSA status (previous infection and recurrences). Appropriate action was taken once the staff found out. The new MRSA procedures are clear that primary care team, community staff, carers and patients themselves have a responsibility to inform admitting ward staff of MRSA history. In addition it should be clearly marked in the medical records. These procedures have been re-iterated to relevant staff. 22

23 9 References 1 Quality Improvement Scotland. Healthcare Associated Infection Standards Watt B et al: The Watt Group Report. Edinburgh: SEHD, SEHD. Infection Control and Cleaning: Nursing Issues HDL (2005) 7. Available at: 4 SEHD. Infection Control: Organisational Issues HDL (2005) 8. Available at: 5 Healthcare Associated Infection Task Force. The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection. Scottish Executive: Edinburgh, NHS Scotland: Sterile Services Provision Review Group: First Report: The Glennie Framework NHS Scotland, Healthcare Associated Infection Task Force. The NHS Scotland National Cleaning Services Specification. Edinburgh: Scottish Executive, Available at: 8 Healthcare Facilities Scotland. Monitoring Framework for National Cleaning Services Specification: Guide for NHS Scotland Managers Version 2. National Services Scotland, Available at: 9 Scottish Executive. Preventing infections acquired while receiving healthcare: The Scottish Executive's Action Plan to reduce the risk to patients, staff and visitors. Scottish Executive, Available at: 10 SSHAIP. Surveillance of surgical site infection for procedures carried out from 1/04/02 30/06/06. Glasgow: HPS, Available at: pdf 23

24 Appendix A: Surveillance Report Communicable Disease and Infection Control Surveillance For the purposes of this annual report, surveillance data have been presented for the six year period April 2003 March 2009 wherever possible. This is with the aim of providing some indication of monthly and seasonal trends. Unless otherwise stated, all data used in this report is from the Shetland NHS Board Public Health Department s surveillance systems. 1 Staphylococcus Aureus Surveillance 1.1 MRSA (Meticillin Resistant Staphylococcus Aureus) MRSA is a bacteria carried by many people that can sometimes cause serious infections, particularly in hospital patients. MRSA is generally identified in two ways: Screening of patients (eg on returning from mainland hospitals) Isolating MRSA as a cause of infection (for example a wound swab or urine test) In Shetland, the Public Health Department collects information on MRSA colonisation and infection and reports these to the Control of Infection Committee. We also take part in the national surveillance system for MRSA bacteraemia (a serious blood infection). All patients transferred from hospitals on the mainland to Lerwick Hospitals are routinely screened for MRSA. Colonisation or infection with MRSA is managed according to local infection control procedures and may include antibiotic treatment for infection, eradication therapy and repeat screening. Local surveillance 25 New cases of MRSA colonisation and infection in Shetland Other infection and colonisation Bacteraemia No. of cases Jan - Mar 04 Apr- June 04 July- Sep 04 Oct- Dec 04 Jan- Mar 05 Apr- July - Oct - June Sept Dec Jan - Mar 06 Apr- July - Oct - June Sept Dec Jan - Mar 07 Apr - June 07 June - Sept 07 Oct - Dec 07 Jan - Mar Apr - Jun Jul - Sept Oct - Dec Jan - Mar 09 Quarter An increase in cases over the last two years reflects the national picture of an increasing problem with community levels of infection, though local numbers remain small. 1