HCAI Local implementation team action plan

Transcription

1 HCAI Local implementation team action plan Item Type Report Authors New Governance HCAI Group Publisher New Governance HCAI Group Download date 16/09/ :12:09 Link to Item Find this and similar works at -

2 HCAI - LOCAL IMPLEMENTATION TEAM ACTION PLAN The HSE has established a New Governance HCAI Group with responsibility to develop action plans, national and local to reduce the potential for spread of infections between persons in the health care setting and to reduce and alter antibiotic use. The recommendations from Surveillance, Diagnosis and Management of Clostridium difficile guidelines have been included The 5 year objectives are: To reduce Health Care Associated Infections by 20% To reduce MRSA infections by 30% and To reduce antibiotic consumption by 20% KEY AREAS INTERVENTION ACTIONS 1.1 e learning programme Ensure any programmes developed by e learning group (nationally) are available for all staff Disseminate Infection Control induction programme to all hospitals and health care facilities and ensure its inclusion in induction programme for all staff. (will be produced nationally) 1. EDUCATION Ensure all new staff have access induction programme Prepare update quarterly of all new staff and their access to programme Ensure patient information leaflets are available for all staff Ensure staff aware of location of best practice advice: add in location of HSE www link 1.2 SKILL training programme Identify all health care staff requiring SKILL training HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 1 Sept 2008 (Includes recommendations from Clostridium difficile

3 1.2.2 Develop schedule to ensure all staff access programme Produce regular progress report for National Governance Group 2.1 Infection Control Standards Ensure HSE Infection Control Standards are incorporated into the institution s service plans 2.2 Infection Control guidelines Make infection control guidelines available to all health care staff Record staff in receipt of the guidelines 2.3 Hand hygiene guidelines Ensure hand hygiene guidelines are available to all healthcare staff incorporate recommendations in national guidelines into service plans 2. STANDARDS Undertake internal audits of hand hygiene at regular intervals (guidance on this will be provided to ensure a standardised approach) 2.4 MRSA guidelines Ensure national guidelines on control and prevention of MRSA are available to all healthcare staff Incorporate recommendations in national guidelines into service plans Ensure key recommendations have been implemented through regular audit 2.5 Infection Control Programme Develop and agree annual infection control programme, in line with HSE Infection Control Standards Ensure infection control programme is implemented through regular review/audit 2.6 Environmental Control programme Develop and agree annual environmental control programme, in line with IHSAB/HIQA National Hygiene Standards HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 2 Sept 2008 (Includes recommendations from Clostridium difficile

4 2.6.2 Ensure cleaning and decontamination protocols are available in facility and undertake regular audits to ensure implementation Ensure environmental cleaning programme is undertaken and that recommendations for cleaning in Irish C. difficile guidelines are implemented Guidelines available at: http: // Z/Gastroenteric/Clostridiumdifficile/Publications/ 2.7 Laboratory services Ensure arrangements in place to undertake laboratory testing of samples Ensure laboratory recording procedures in place to allow information to be collected and collated 3.1 MRSA in ITU Ensure staff (ITU and laboratory) aware of data collection Identify staff responsible for data collection 3.2 Staphloccus aureus bacteraemia rates Ensure data collected and sent to HPSC Ensure staff aware of data collection Identify relevant staff for collection of data 3. SPECIFIC HOSPITAL TARGETS 3.3 Antibiotic consumption surveillance Ensure data collected and sent to HPSC for collation and feedback Ensure feedback is provided to relevant staff Inventory of Pharmacy staffing in hospitals including their roles and responsibilities Identify systems in place to collect standardised antibiotic consumption Collect data as per nationally agreed dataset HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 3 Sept 2008 (Includes recommendations from Clostridium difficile

5 3.4 SSI Disseminate standardised definitions to all relevant staff (once produced nationally) Identify staff involved in SSI surveillance and control (this will be dependent on national definitions) Ensure national core data set collected and sent to HPSC Ensure feedback from nationally collated data from HPSC to all relevant staff 3.5 Surveillance Ensure surveillance is being undertaken and data provided to LIT. Regional Infection Control Committees to provide support and advice in interpretation and management of this data Ensure protocol in place regarding testing of stool samples who, why, Hospital Manager/ Hospital CEO/ LHM and where sent etc (Details of testing to be done outlined below) In outbreak setting and in patients with severe C difficile infection, ensure appropriate arrangements are in place to allow samples to be referred to a reference laboratory for epidemiological typing or stored at 4 o C for culture at a later stage 4. SPECIFIC COMMUNITY TARGETS 5.1 Antibiotic stewardship in hospitals Ensure SARI recommendations on antibiotic stewardship in hospitals are disseminated to all healthcare institutions Ensure antibiotic stewardship programmes are disseminated to relevant staff (will be HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 4 Sept 2008 (Includes recommendations from Clostridium difficile

6 developed nationally) Ensure implementation of recommendations Monitor implementation of recommendations through regular internal audit 5.2 Hospital antibiotic prescribing guidelines for treatment and prophylaxis Get inventory of antibiotic prescribing guidelines available in each hospital Make standardised prescribing guidelines available to all relevant staff (once available nationally) 5. ANTIBIOTIC USE Ensure guidelines are implemented through regular audit Ensure stewardship programme available to guide antibiotic prescribing Ensure antibiotic prescription data is reviewed on a regular basis 5.3 Community antibiotic prescribing guidelines Ensure antibiotic liaison pharmacy input is available in institution and ensure its prioritisation within service Get inventory of antibiotic prescribing guidelines in all community hospitals/ long stay facilities/nursing homes etc Disseminate community prescribing guidelines to all community hospitals/long stay facilities/nursing homes (when available nationally) 6.1 Input into new build plans Ensure input from Infection Control Team into any new build or refurbishment at the design/planning stage Revise any current protocols/processes to take account of this 6.2 Isolation facilities Inventory of isolation facilities in each facility including description of each HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 5 Sept 2008 (Includes recommendations from Clostridium difficile

7 6.2.2 Ensure implementation of any future guidelines in relation to provision of isolation facilities 6. FACILITIES 6.3 Hand hygiene facilities Identify gaps in relation to provision of adequate hand hygiene facilities in each facility as per national guidelines Develop programme of work to address gaps identified Ensure alcohol gel available throughout each healthcare facility Identify person(s) to ensure stocks are maintained Monitor use of hand gel. Report volume used per 1000 bed days each quarter Ensure recommendations in Guidelines for hand hygiene in Irish healthcare settings are implemented. Available at: Environment Disseminate national guidelines on cleaning and disinfection to all relevant healthcare staff Identify person(s) with responsibility for ensuring these guidelines are implemented Undertake annual internal audit of cleaning and disinfection procedures (national standards set) Ensure appropriate waste management facilities in place as per national guidelines HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 6 Sept 2008 (Includes recommendations from Clostridium difficile

8 6.4.5 Identify person(s) with responsibility for ensuring such are in place for same Undertake annual internal audit of waste management procedures 7.1 Governance Structure Inventory of current governance structures i.e. SARI committees, regional ICC, hospital ICC, community ICC, hospital, and community ICT and membership and terms of reference of each Ensure nationally agreed governance arrangements are in place Agree governance and connection at LIT level and connection with Local and National structures Produce monthly report for LIT (as per template agreed nationally) 7. MANAGEMENT Ensure clear communication occurs at all levels staff, ICT, management, LIT and Regional Infection Control Committees 7.2 Professional advice Identify persons or groups who will provide professional advice in relation to infection control within each facility i.e. ICT/ICC/ SARI etc 7.3 Identification of responsibility and accountability Nominate person(s) with responsibility for infection control within each area within each facility e.g. theatre, ITU, CCU and at each ward level Ensure infection control is prioritised from within resources adequate isolation facilities, hand washing facilities (refer to Guidelines for hand hygiene in Irish healthcare settings available at: Z/Gastroenteric/Handwashing/Guidelines/, ensuites facilities and adequate staffing levels Ensure protocols in place to allow prompt isolation of patients who are an infection control risk Ensure risk incident forms completed when patients cannot be isolated and forms HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 7 Sept 2008 (Includes recommendations from Clostridium difficile

9 reviewed on a regular basis Ensure patient movement and transfer protocols are in place as outlined in national C. difficile guidelines (available at: Z/Gastroenteric/Clostridiumdifficile/Publications/) to ensure staff and receiving facilities are aware of infection control risk and what procedures must take place - details of patients infection risk should be outlined on the transfer form In an outbreak situation, ensure there are clearly defined and documented management processes and procedures outlining the roles and responsibilities of OCT members as outlined in national C. difficile guidelines Clostridium difficile - Initial testing All diarrhoeal specimens from patients 2 years and over should be tested for C. difficile (Diarrhoeal stool specimens are defined as those that take up the shape of their container) In the case of ileus and suspicion of C. difficile infection, contact the microbiologist as testing of formed stool is acceptable and other diagnostic procedures (e.g., abdominal CT, colonoscopy) may be required In the case where clinical suspicion of C. difficile infection is high, yet C. difficile toxin is negative, contact the microbiologist as patients should be retested and if negative, the specimen set up for C. difficile culture followed by toxin testing Storage of specimens Specimens for transportation or specimens which cannot be examined promptly should be refrigerated at 4 o C in a designated specimen refrigerator. Laboratory methods All laboratories should use a method that can detect both toxin A and toxin B HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 8 Sept 2008 (Includes recommendations from Clostridium difficile

10 C. difficile can be isolated by culturing faecal samples directly onto selective agar. Media can be pre-reduced and a pre-inoculation process of heat or alcohol shock performed in order to enhance isolation The physician/surgeon or general practitioner involved in the patient's care is to be informed immediately of all positive C. difficile toxin results Retesting Once the diagnosis of C. difficile infection is confirmed, patients should not be retested for C. difficile toxin when on treatment. If recurrence of diarrhoea after a symptom-free interval occurs, a repeat specimen should be tested for C. difficile toxin and other potential causes of diarrhoea excluded Performing a test of cure or clearance on stool specimens after C. difficile treatment is not recommended When to send specimens for typing 1. In cases of severe C. difficile infection 2. In an outbreak setting Recommended Membership of a CDAD Outbreak Control Team Acute Hospital HSE PCCC Chair Hospital CEO, Network Manager or General Manager Local Health Office Manager Team Department of Public Health Specialist/ Department of Public Health Specialist Medical Officer of Health* /Medical Officer of Health* Consultant Physician/Surgeon Attending Medical Officer or General Practitioner Occupational Health Physician Occupational Health Physician Consultant Medical Microbiologist Consultant Medical Microbiologist HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 9 Sept 2008 (Includes recommendations from Clostridium difficile

11 Infection Prevention and Control Nurse Infection Prevention and Control Nurse Infectious Disease Physician Healthcare Facility Manager or representative Surveillance Scientist Surveillance Scientist Director of Nursing Matron/Charge Nurse Ward/Department nurse manager of affected area (s) Ward/Department nurse manager of affected area (s) Bed Manager Patient Services Manager/ Household Services Manager Patient representatives office Other relevant staff as considered necessary which may include a communications/press officer, a laboratory representative, an antibiotic pharmacist (if present in the facility), and a public health nurse (in a Nursing Home outbreak). *The MOH will notify the National Director for Population Health and the HPSC. HCAI LOCAL IMPLEMENTATION TEAM ACTION PLAN V4 Updated 10 Sept 2008 (Includes recommendations from Clostridium difficile