Report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead, Infection Prevention & Control

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1 INFECTION PREVENTION & CONTROL ANNUAL WORK PLAN ( ) 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 Lead, Control The Board is asked to: Note and Approve the Control Work Plan Background NHS Quality Improvement Scotland (QIS) Healthcare Associated Infection (HAI) Standard 3b.3 requires Boards to develop an Annual Control Work Plan and Monitoring Programme. 2 Annual Work Plan During last year significant progress has been made with embedding the culture of Infection Prevention & Control being Everyone s Business. NHS Highland has low infection rates and, far from being complacent, is aware that much work still needs to be done. This year s Annual Work Plan encompasses ten areas for action to prevent and control infection:- 1. HEAT Targets for Staphylococcus aureus and Clostridium difficile 2. Control Staffing resource 3. Control is everyone s business 4. HAI Standards 5. HAI Education 6. Surgical Site Infections 7. Decontamination 8. Water Safety 9. Domestic Services 10. Catering Services Information in respect of each area is contained in Appendix 1. The plan will be monitored by the Infection Control Improvement Group. A detailed RAG rated action plan will be submitted quarterly to the Control of Infection Committee and 6 monthly to the Board. 3 Contribution to Board Objectives The Control Annual Work Plan supports NHS Highland s achievement of the HEAT Target relating to infection control. 4 Governance Implications By meeting the requirements of the Annual Work Plan, NHS Highland will continue to improve its performance in respect of Staff, Patient/Public Involvement and Clinical Governance Standards and fulfill, in part, the requirements of the Scottish Government Guidance. Liz McClurg Infection Control Manager 24 May 2013

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3 APPENDIX 1 NHS Highland Control Annual Work Plan 2013/2014 Objective Activity Timescale Lead Officer 1.HEAT Targets 1.1 To continue to reduce the number of SAB cases to achieve the HEAT Target of 24 cases per 100,000 acute occupied beds days or lower by March 2015 a) By ensuring 95% compliance with device maintenance bundles in Raigmore and the District General hospitals PVC CVC Devise & implement PICC maintenance bundle CAUTI b) Where applicable, roll out the use of maintenance bundles to all other healthcare settings. c) By raising awareness of and reinforce compliance with NHS Highland wound management guidelines & formulary. a) By reviewing the causes of community acquired SABs, to give an understanding of what preventative measures are required. b) By reviewing the causes of healthcare acquired SABs, to give an understanding of what preventative measures are required To reduce the number of Clostridium difficile cases to achieve the HEAT Target of 25 cases per 100,000 occupied bed days in patient s age 15 years and over by March By monitoring the adherence to the Clostridium difficile policy to highlight areas for improvement a)hand hygiene compliance with remedial action if compliance is less than 95% b)continue to improve empiric and prophylactic antimicrobial & proton pump inhibitor prescribing

4 c)environmental cleanliness & fabric maintenance d)appropriate isolation and monitor compliance a)by ensuring the delivery of the most appropriate laboratory testing 2. Control Staffing resource b)by ensuring that up-to-date infection rates are widely disseminated 2.1 To initiate Control service project plan to look at what resource is required to ensure that all disciplines of staff across Highland have access to specialist infection prevention & control advice and guidance. a) By identifying current resources within the IP&CT. b) By reviewing where infection prevention & control input is required in each operational unit, exploring how this can be delivered. Infection Control Manager Supported by Lead Nurses. c) By reviewing the structure of the IPC service to ensure effective teamwork. d) By reviewing the role of the Control Nurse ensuring time is built into job plans for education & training. e) By reviewing the role of the IP&C Link Nurse Practitioner 2.2 To review the use of Control Doctor resource and agree a model of sustainable provision with the Operational Units. a) By identifying where infection prevention & control input is required in each operational unit, exploring how this can be delivered. Consultant Microbiologist, Strategic Lead for Infection Prevention. 4

5 3. Control is everyone s business 3.1 Embed the importance of Infection Prevention & Control into everyday practice. a) By undertaking the rolling programme of Standard Infection Control Precautions compliance monitoring. b) By ensuring that there is Control input in all new builds/refurbishments as per HAI Scribe. c) By ensuring that there is Control input in procurement of reusable equipment d) By identifying and reporting non- compliant sinks & poor fabric condition. 4.HAI Standards e) By auditing compliance with NHS Scotland MRSA Screening policy. 4.1 Embed the process and governance arrangements for HAI Standards Monitoring. a) By ensuring there is a programme of HAI standards monitoring visits in each Operational Unit. b) By ensuring that there is a system in place to escalate any actions which cannot be progressed through the line management structure and if necessary to the Chief Operating Officer. 5.HAI Education c) By submitting quarterly reports to the Infection Control Improvement Group. 5.1 Through the HAI Education Group:- To ensure Patient/Service Users safety is achieved in relation to Control by standardising HAI education and training, targeted at different staff groups a) By implementing the recommendations of the HAI Education Group b) By addressing the barriers preventing HAI training 5

6 across NHS Highland in Hospitals Community Primary Care Care Homes Care at Home Adult Day Care Centres Learning Disability Bank Staff Social Work Staff Volunteers and Contractors 6.Surgical Site Infections 6.1. To reduce elective colorectal surgical site infections to 10% for 6 consecutive months 6.2. To maintain in year rate of <5% for elective and emergency Caesarean Section Surgical Site Infections 6.3. To maintain Orthopaedic Surgical Site Infections at <1% by. 6.4 Comply with all HPS mandatory surveillance c) By ensuring that there is a robust system of recording of what training has been undertaken By the development and adherence to the Colorectal infection reduction action plan Colorectal Team By maintaining adherence of current practice. Obstetric & Midwifery Teams By continuing the present process of RCA of infections, surveillance and feedback a) By reviewing the resource required. b) By setting up systems and processes to enable the collection of SSI data. c) To further the rollout of the ICNet electronic surveillance system to include Argyll & Bute CHP and with the addition of the admission, discharge and transfer tracking programme. Orthopaedic Team Infection Control Manager 6

7 7.Decontamination 7.1 Improve compliance with all aspects of decontamination. a) By ensuring that there are systems, processes and facilities for safe endoscopy decontamination. NHS Highland Decontamination Group a) By putting systems in place around procurement of equipment to ensure effective decontamination. b) By ensuring that there are systems, processes and facilities for safe decontamination. c) By ensuring that there are plans in place for all (General Dental Practitioners) GDP independent contractors to be able to provide LDU facilities within their practices for the decontamination of instruments which are compliant with SHPN 13 Part 2. 8.Water Safety 8.1 Through the Water Safety Group, ensure NHS Highland has robust and consistent arrangements in place for the safety of the water systems in NHS Highland comply with legal duties and relevant guidance a) By implementing procedures for the prevention of water-borne infection which include risk assessment, analysis and planned preventative maintenance. b) By ensuring that daily water flushing is carried out to reduce the risk of water borne infection in accordance with the SOP. 9.Domestic Services 9.1 To support Domestic Services to achieve 90% Cleaning compliance. a) By the development and implementation of Standard Operating Procedures (SOPs), including products used and reports to Senior Charge Nurses NHS Highland Professional Lead for Soft Facilities Services b) By the development and implementation of Domestic Services SOPs Training c) By the development and implementation of Domestic Services Standard Monitoring Procedures and Monitoring Training. 7

8 d) By assessing Domestic Services staffing levels based on the agreed SOPs. e) By monitoring the implementation of COSHH procedures & Risk Assessments. 10. Catering Services 10.1 To support Catering Services & Clinical Staff to ensure food safety from production to delivery. a) Through education & training such as Elementary Food Hygiene Certificate Hazard Analysis and Critical Control Points (HACCP) Training Food Service at Ward Level NHS Highland Professional Lead for Soft Facilities Services b) By monitoring compliance with food safety standards. 8