CATEGORY OF PAPER. Board of Director s Meeting 27/07/2017. J A Mains & V Mccluskey. Key considerations

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1 CATEGORY OF PAPER Specific action required (decision / approval) For information / assurance only CATEGORY OF PAPER Specific action required: Provides Assurance: For Information: Report title: Purpose of report: Key issues: (key points of the paper, how this supports the achievement of the Trust s corporate objectives, overview of risk implications, main risk details on page 2) Board of Director s Meeting 27/07/2017 Infection Prevention and Control Annual Report and work plan 2017/18 To provide an overview of the work undertaken by the IPC team during and inform the members of the 17/18 work plan. Policy Review and Development Education Statutory & Mandatory and Induction Training Annual Inspection Programme Service and Building Developments Serious Incidents and Complaints - None Achievements, Risks and Mitigations Issue previously considered by: Recommended actions: Sponsor / approving director: Report author: Governance and assurance Link to trust corporate objectives: (please tick) Link to CQC / KLOE: (please tick) Any relevant legal / statutory issues? (Such as relevant acts, regulations, national guidelines or constitutional issues to consider) Equality analysis completed If this is not relevant please explain why: Key considerations IPC issues are reported to and discussed at PSG To review and approve the IPC Annual Report for To review and approve the work plan for Jo Baxter J A Mains & V Mccluskey Caring Responsive Effective Well Led Safe CQC, HSE, Health and Social Care Act Yes No Not Relevant Details Page 1 of 28

2 Confirm whether any risks that have been identified have been recognized on a risk register and provide the reference number: Note that the Board and its committees this should include references to the BAF and ORR where appropriate. IPC staff resources RA Sharps actioned and closed Please specify any Financial Implications Please explain whether there are any associated efficiency savings or increased productivity opportunities? Consider: Will the delivery of a Trust CIP be impacted? Has a new Trust CIP been identified? Will additional costs be incurred? Will additional income be received? Will there be related financial implications for another trust department / service? Are any additional resources required e.g. staff capacity? The Trust has one IPC manager; capacity to monitor trust wide is stretched; Administrator IPC champions need to be identified within the service lines. Is there any current or expected impact on patient outcomes/experience/quality? Specify whether appropriate clinical and/or stakeholder engagement has been undertaken: (stakeholders could include staff, other Trust departments, providers, CCGs, patients, carers or the general public) Are there any aspects of this paper which need to be communicated to our stakeholders (internal or external)? (Please tick if yes then please complete all boxes. Please briefly specify the key points for communication and ensure the Comms team are informed via mailto:publicrelations@neas.nhs.uk) For example: Will services / experiences improve for patients? Will the proposed changes pose a risk to quality / outcomes? Quality issues to consider (in terms of patient safety, clinical effectiveness, patient experience) Collaborative Safer Sharps initiative undertaken with the introduction of safer sharp devices. IPC and Procurement have commenced a new premises cleaning contract with Cordant from January NEAS IPC and Research team leading on a national research collaboration into the cleaning of vehicles. IPC and the informatics team have created a platform to enable electronic auditing. Emergency care service line will trial and utilise this system. Yes No Positive Negat Proactive Reactive Internal Exter Please enter specified points *The Trust corporate objectives are: 1. To continuously improve the quality and safety of our services, ensuring the CQC fundamental standards are achieved and patient outcomes are improved. 2. To achieve financial break-even position in 2017/ To improve organisational culture, aligned to Trust mission, vision and values to achieve delivery of our strategy. 4. Develop a future workforce with the correct staffing levels and skill mix across both clinical and non-clinical functions to support safe, effective and compassionate care and employee well-being. 5. To deliver the agreed Transformational and Vanguard programmes. 6. To plan, agree and implement a front line operational delivery model aligned to current and future need and planned performance improvement. Page 2 of 28

3 Infection Prevention and Control Annual Report April 2016 March 2017 Vince Mccluskey Infection Prevention and Control Manager & Jacqui Mains Infection Prevention & Control Manager Page 3 of 28

4 Contents Title... 3 Content Table... 3 Executive Summary... 5 Key achievements in 2016/ Key risks and mitigations:... 6 Key priorities Introduction Background Corporate Responsibility The Patient Safety Group (PSG) Education & Training IPC Annual Audit Programme Service and Building Developments Serious Incidents and Complaints Key Achievements, Risks and Mitigations Appendix A IPC Plan Appendix B IPC Annual Audit Plan Page 4 of 28

5 Executive Summary The purpose of this report is to inform the Trust of the progress made against the Care Quality Commissions standards (Outcome 8, Regulation 12) and the Department of Health Health and Social Care Act 2008 (amended 2010) during the period 1 April 2016 to 31 March 2017 An outline of the Infection Prevention and Control (IPC) Annual Work Programme for 2017/18 is appended to the report to illustrate the priorities for the forthcoming year (Appendix 1).The report provides information and evidence of the ongoing commitment of the Trust to embed IPC principles and practices throughout the organisation and shows the significant improvement the Trust has made in this respect. As a result of learning and improvement North East Ambulance Service (NEAS) has a workforce that has the knowledge, skills and experience to appropriately minimise infection risk for patients and staff, thereby improving patient safety and staff wellbeing. The organisation is able to demonstrate compliance with infection prevention and control standards and delivery of key strategic objectives including: Delivering high quality, patient focused services and Ensuring a highly skilled, motivated and engaged workforce. Key Achievements in 2016/2017 The Care Quality Commission inspected NEAS in April 2016 against compliance with the CQC Outcome 8 standards for cleanliness and infection prevention. NEAS was overall rated Good with Infection Prevention and Control showing outstanding practice and no issues identified. The team have continued to maintain a high level of IPC awareness through communications to staff in a variety of formats including; The introduction of an IPC dashboard, Patient Care Updates, the Summary, Emergency Care Clinical Manager (ECCM) and Patient Transport Services Team (PTS) Leader meetings. Good communications with regional NHS Trusts and Public Health England continue to be beneficial ensuring that timely information is shared across organisations with regard to health care associated infections and infectious diseases. Increased monitoring including: ECCM observational practice audits using an electronic auditing tool and PTS team leader audits including vehicles and bare below the elbow (BBE). Provision of education and training with updated mandatory and induction infection control materials. There have been no formal complaints relating to infection prevention and control during 2016/17 this is taken to reflect positive patient experience. Page 5 of 28

6 Key Risks and Mitigations: The key risks from IPC associated issues include: Inappropriate waste and sharps disposal present a patient and staff risk including inoculation injury. Education and training focused in this area to mitigate the risk. The introduction of safer sharps devices was established during 2016 being introduced to the statutory and mandatory training programme. A review of the risk in August 2016 identified substantial reduction in sharp incidents therefore this risk was closed on the risk register. Infection Prevention & Control Resources were identified as a risk due to the IPC audit and training work load. An additional IPC manager was in place on a six month secondment from April 2016 September 2016 who supported the IPC work plan. Staff on alternative duties have assisted in the audit programme throughout the year. Maintaining vehicles cleanliness with associated monitoring of cleaning processes has been identified as a risk. Vehicle cleanliness audits were carried out by the IPC team and by ECCM s and PTS supervisors. NEAS have led on a national ambulance service research project aiming to identify optimal vehicle cleaning processes. Research findings and recommendations are due to be reported in May Emerging infectious diseases and antimicrobial resistance is a national threat. Key priorities The work plan for can be seen in appendix A IPC resources to be appropriate including IT / data repository resources to support monitoring of quality assurance indicators including real time IPC dashboard. High Impact Intervention Care Bundles for Hand Hygiene, Personal Protective Equipment and Aseptic Non Touch Technique relating to Intra Vascular Devices are embedded into practice and monitored through IPC Audit cycles. All services that are provided in NEAS premises and vehicles demonstrate a high level of cleanliness and have robust monitoring processes. Third Party Contractors - NEAS will re-establish links with all third party providers to ensure that they are following all guidance in relation to IPC. Page 6 of 28

7 1. Introduction This is the Infection Prevention and Control (IPC) Annual Report from the Director of Quality and Safety, Director IPC (DIPC). The report is to inform the Board of the progress made against the Care Quality Commissions standards (Outcome 8, Regulation 12) and the Department Health Health and Social Care Act 2008 (amended 2010) during the period 1 April 2016 to 31 March An outline of the Infection Prevention and Control (IPC) Annual Work Programme for 2017/18 is appended to the report to illustrate the priorities for the forthcoming year (Appendix A). The report provides information and evidence of the ongoing commitment of the Trust to embed IPC principles and practices throughout the organisation and shows the significant improvement the Trust has made in this respect 2. Background Effective infection prevention and control practice requires ownership at every level from Board to frontline. Success depends on creating a managed environment that minimises the risk of infection to patients, staff and the public and ensures compliance with relevant national and local standards, guidance and policies. Through personal accountability, skilled and competent staff, transparent and integrated working practices and clear management processes a sustained approach to IPC can be achieved The Health and Social Care Act 2008 (amended 2010): Code of Practice for Health and Social Care on the Prevention and Control of Infections and related guidance (Department Health). Section 21 of the Health and Social Care Act (2008) enables the Secretary of State for Health to issue a revised Code of Practice. The Code contains statutory guidance about compliance with the registration requirement for cleanliness and infection control. The Act states that the Code must be taken into account by the Care Quality Commission (CQC) when decisions are made regarding the cleanliness and infection control standards required to achieve registration. The Code, revised in December 2010, focuses on 10 areas which are captured within the work plan. (Appendix A) 3. Corporate Responsibility In December 2003 the Department of Health published Winning Ways: Working Together to Reduce Healthcare Associated Infections which highlighted the requirement for a Director of Infection Prevention and Control (DIPC). The Director of Quality and Safety has been designated as the DIPC with lead responsibility within Page 7 of 28

8 the Trust for IPC. This post reports directly to the Chief Executive Officer and the Trust Board. The Trust Board holds overall responsibility for ensuring that the Trust is compliant with IPC national guidance. 4. The Patient Safety Group (PSG) The aim of the PSG is to provide assurance to the Trust Board that all services are provided in a clean and safe environment through the effective performance monitoring of key performance indicators (KPIs). It provides a forum for the coordination of any IPC related projects ensuring a consistent approach to IPC throughout the Trust. The PSG group is responsible for providing assurance to the Quality Governance Group (a sub-committee of the Board) during met monthly The Infection Prevention and Control Team Director Infection Prevention and Control (DIPC) The responsibilities of the DIPC are outlined in Winning Ways (DH, 2003) and include: To be the responsible Executive Lead for IPC within the Trust reporting directly to the Chief Executive To ensure that pre-determined targets are met by overseeing the IPC work programme and Annual IPC Inspection Programme Present regular reports to the Trust Board Head of Patient Safety The responsibilities of the Head of Patient Safety include: Ensuring Trust policies and procedures reflect the national and local IPC requirements and are reviewed within timescales. Overseeing the delivery of an effective performance monitoring programme developed by the IPC manager and reporting through the PSG Group to the Quality Governance Group. Overseeing the delivery of an annual work programme developed by the IPC manager focusing on improving and sustaining compliance with the Health and Social Care Act (2008) Oversee production of IPC annual report Contributing to the Quality Governance Report for submission to the Trust Board Page 8 of 28

9 IPC Manager Providing specialist IPC advice in all areas of clinical practice Develop IPC educational programmes including workbooks for clinical and non-clinical staff for induction and mandatory training. Facilitating quality assurance monitoring and report compliance with IPC policies to PSG on a monthly basis Ensure there is a robust vehicle cleaning regime in place meeting best practice and gain assurance monthly that this is being adhered to and report to PSG Review IPC policies and procedures ensuring they are up to date and reflect best evidenced based practice. Monitor themes and trends from IPC incidents including needle stick injuries and report to PSG monthly. Facilitate IPC Operational Champions network, supported via newsletters and educational opportunities. Produce annual IPC report. Monitoring IPC training and report compliance for mandatory IPC training in the annual report. Prepare IPC work plan for year ahead and facilitate delivery. Review and develop quality assurance integrated inspection tools to ensure these are fit for purpose. 4.2 Policy Review and Development All IPC policies and procedures were reviewed and ratified as appropriate in March 2016 in response to national guidance/ legislation. All policies and procedures are available on the Trusts Q Pulse policy system and the Trust intranet IPC page was updated April Education & Training Compliance with Mandatory Education & Training Two thousand four hundred and sixteen staff completed EAT this represents a trust compliance of 95%. A 6% increase is reported from the previous year and demonstrates excellent compliance. Compliance by Patient Transport Service and Emergency Care Services is reported as 96%. Compliance by Support Services and Contact Centre is reported as 94%. Two hundred and ninety-six staff attended a corporate induction programme that included an infection prevention and control session representing an 80% compliance rate. Page 9 of 28

10 Compliance for IPC induction for operational staff: Allied Health Professionals, sixty new starters: fifty-three attended IPC induction = 83% compliance. Medical & Dental, three new starters: none attended IPC induction = 0% compliance. Nursing & Midwifery two new starters, both attended IPC induction = 100% compliance. The management of sharps was identified as requiring further training and education following a sharps incident investigation and safe sharp training was provided to specific groups. The education and training programme for is progressing to an Infection Prevention & Control e-learning module for all staff, this should improve induction compliance. Additional taught sessions regarding clinical waste management/sharps, antimicrobial resistance (AMR) and personal protective equipment are being facilitated as part of PTS and EC Staff mandatory training. 6. IPC Annual Audit Programme 6.1. Monitoring Systems A key risk identified was insufficient IPC staff resources to carry out comprehensive monitoring. Previous IPC annual reports reported incompletion of planned audit schedules. It is reported for the planned schedule of monitoring was achieved including for the first time IPC practice: hand hygiene, wearing of PPE, aseptic technique, and safe handling of sharps. Audit activity included ECCM s conducting observational audits on practice using an electronic application. PTS managers conducting staff and vehicle audits. SSO s completing station cleanliness audit data. The processing and reviewing of increasing audits requires IPC resources and further development of the electronic application to enable real time information via a dashboard. A summary of IPC Audit Schedule with Compliance is given in Appendix A of this report. Audits carried out in include: Station cleanliness audits Vehicle audits Practice Audits for EC Staff Hand Hygiene, Aseptic Technique, BBE Bare Below the Elbow for EC and PTS Staff Page 10 of 28

11 6.2 Station Cleanliness Audit There are currently fifty-two stations open at NEAS (April 2017) during Fifty ambulance stations were included in the IPC cleanliness audit schedule and all had at least one cleanliness audit carried out. Barnard Castle is in the process of moving to a new location and Blyth has moved to a co-location area and was not included in the IPC audit plan. The results of the station audits carried out by the IPC manager reported: Green % 25 stations 50% Amber 90-94% 18 Stations 36% Red 89% or below 7 Stations 14% Commencing June 2016 Station Support Officers (SSO s) carried out 246 station audits using the IPC electronic application. Prior to this sixty audits had been completed on paper April July 2016 making a total of three hundred and six audits. Average results are reported by month and also by cluster: Years Month Score No of Audits 2016 Jun 74.3% 2 Jul 91.2% 3 Aug 76.8% 18 Sep 81.4% 42 Oct 86.2% 31 Nov 83.6% 43 Dec 88.6% Jan 88.7% 25 Feb 88.9% 26 Mar 85.9% 30 Grand Total 85.0% 246 Cluster Score No of Audits Alnwick Cluster 70.3% 15 Backworth Cluster 82.0% 16 Bishop Cluster 88.0% 37 Blucher Cluster 77.3% 23 Coulby Cluster 84.9% 8 Hartlepool Cluster 87.9% 35 Lanchester Road Cluster 92.2% 32 Monkton Cluster 85.3% 31 Pallion Cluster 83.6% 30 Stockton Cluster 86.4% 19 Grand Total 85.0% 246 Page 11 of 28

12 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 91.2% 88.6% 88.7% 88.9% 86.2% 83.6% 81.4% 85.9% 74.3% 76.8% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Sum of Score Number Trend Chart showing number of SSO cleanliness audits with sum of score Identified poor compliance from the station cleanliness audit: Hospital laundry on site, clinical stores not put away promptly, stores not rotated and clinical store cupboard not clean is being monitored by the Patient Safety Group. The quality measures are monitored by the Patient Safety Group. 6.3 Vehicle Audits Patient Transport Service Infection Control carried out sixty-five PTS vehicle audits from May July 2016 identifying an issue regarding out of date decontamination wipes was resolved by removing from vehicles, alcohol gel not being available and waste segregation. 11 Infection Control PTS Vehicles Audits May- July top non compliant items Clinical sporicidal wipes in date Waste managed appropriately Alcohol gel dispenser and product available Page 12 of 28

13 Commencing July 2016 infection control audits were carried out by PTS team leaders. Four hundred and fifty-eight Vehicle Cleanliness Audits and three hundred and twenty Bare below the Elbows audits were completed in Compliance has been fed back to the PTS team leaders and reported to the Patient Safety Group including 100% PTS staff reported as being 100% compliant with BBE. In the last quarter from the 80 vehicles audited 71 scored 100%. Reported noncompliance: is ten vehicles did not segregate waste correctly and one vehicle had a single use item out of date. Quarter Vehicle Cleanliness Audits BBE Audits BBE Compliance July - September % Oct- December % Jan March % Total % 6.4 Vehicle Audits Emergency Care Services Infection Control completed 74 Emergency Care Vehicle Audits April July 2016 that were reported to ECCMs and to the Patient Safety Group. Infection Control Emergency Care Vehicle Audits April July 2016 April May June July Red Green Total Items of non-compliance included straps not clean, suction unit not clean, yellow bags and alcohol gel not available. Page 13 of 28

14 April-July 2016 Infection Control EC Vehicle Audits RAG Rated April May June July Red Green Total Audits ECCM s also carried out One hundred and fifty four vehicle audits as part of their observational audit via the electronic application. In addition from June 2016 Eightytwo Vehicle Spot Checks audits were carried out by ECCM s bringing a total of Two hundred and thirty six emergency care vehicles. This can give assurance that ECCM s are checking vehicles cleanliness. Lower compliance items were the same as the IPC audits providing verification of the audits: The lowest scoring item being the suction unit not being clean. These issues are to be addressed for improvement in Chart showing: Vehicle Cleanliness Audits taken from ECCM observational data by cluster. Cluster Sum of Percentage Vehicles Audited Alnwick Cluster 94.4% 30 Backworth Cluster 82.5% 6 Bishop Cluster 100.0% 4 Blucher Cluster 98.0% 15 Coulby Cluster 100.0% 3 Hartlepool Cluster 97.4% 10 Lanchester Road Cluster 95.6% 31 Monkton Cluster 100.0% 25 Pallion Cluster 94.6% 14 Stockton Cluster 95.7% 16 Grand Total 96.1% 154 Page 14 of 28

15 6.5 ECCM Observational Audits ECCM observational audits were introduced in April 2016 using an electronic application that can be used on ride outs by ECCM s to undertake practice audits on staff members. One hundred and fifty four audits / ride outs were submitted via the application by thirty eight ECCM s. April to August 2016 some ECCM s completed paper audits this data has been included in the table below reporting a total of two hundred and thirteen audits undertaken resulting in the auditing of three hundred and eighteen staff. Month Staff Audited Ride Outs/Audits April May June 27 8 July August September October November December January % February March % Total Observational audits undertaken by ECCM s were reported from the following cluster areas. Data taken from the electronic data. Cluster Number Alnwick Cluster 30 Backworth Cluster 6 Bishop Cluster 4 Blucher Cluster 15 Coulby Cluster 3 Hartlepool Cluster 10 Lanchester Road Cluster 31 Monkton Cluster 25 Pallion Cluster 14 Stockton Cluster 16 Grand Total 154 Page 15 of 28

16 6.6 Hand Hygiene Compliance Hand hygiene compliance has been monitored by the ECCM s using the 5 moments of hand hygiene standard as the NEAS Hand Hygiene policy 2016 and reported to the Patient Safety Group from July Month Opportunities for hand hygiene Opportunities Taken / Compliance Compliance July % August % September % October % November % December % January % February % March % Total % Compliance with Bare below the Elbow Compliance with staff being bare below the elbow has improved over the year with the last quarter reporting all staff observed as 100% Bare below the Elbow EC Staff Month Observed Compliant Compliance Percentage July % August % September % October % November % December % January % February % March % Total % Page 16 of 28

17 Compliance with EC staff wearing alcohol gel Alcohol gel use has been encouraged in the NHS since the 2006 Clean your hands campaign aimed at increasing hand hygiene compliance in health care workers. The audit question relating to staff wearing alcohol gel was added to the electronic application in September Reported compliance requires improvement in the forthcoming year. EC Staff member is wearing alcohol gel Staff Compliance Month Staff wearing gel Percentage September % October % November % December % January % February % March % Total % 6.7 Aseptic Non Touch Technique (ANTT) Patients having an intra vascular device inserted are high risk of developing a health care associated infection the procedures for insertion requires an ANTT technique to help minimise the risk. EPIC (2014). ECCM s audited fifty-eight paramedics inserting cannula during ride outs with a total of fifty-eight 93% staff being fully compliant with using an ANTT. IV cannulation compliance Month Observed Compliant Percentage July August September October November December January February March Total % Page 17 of 28

18 6.8 Personal Protective Equipment ECCM s have reported poor compliance with staff wearing personal protective equipment including gloves and aprons. Infection Control have responded to this and are facilitating education sessions feeding back to clinical staff the observational audits results and a session is now included in the mandatory training for clinical staff to help improve future compliance. Personal Protective Equipment Month Observed Compliant Percentage Opportunities July % August % September % October % November % December % January % February % March % Total % 6.9 The Annual IPC Audit plan for can be seen in Appendix B 7. Service and Building Developments The IPC Manager provided advice to ensure that design of new buildings or changes to existing ones are fit for purpose and meet the required standards for IPC legislation, guidance and best practice. The results of IPC premise and station audits have identified estates issues relating to IPC non-compliances, these are reported and rectified as soon as possible by the Estates and Facilities team. 8. Serious Incidents and Complaints NEAS has reported no Serious Incidents related to IPC. For 2016/17 there have been no IPC-related Formal Complaints/PALS 9. Key Achievements, Risks and Mitigations Key achievements in 2016/17 include the implementation of the electronic auditing tool allowing us access to much more frequent data about the estate, vehicles and staff. Page 18 of 28

19 Risks Emerging infectious diseases remains a global threat and have a potential to impact upon the UK population. Middle Eastern Respiratory Syndrome (MERS) is still a concern for people travelling from affected areas. Lessons learned from the Ebola response were used to ensure all plans in place are tested and effective and updated where required. Increasing antimicrobial resistance impacting upon health care systems can be seen including the emergence of Carbapenem resistance in the North East of England. An IPC risk assessment tool for operational staff has been approved at PSG in May 2017 and will be piloted in Antimicrobial resistance (AMR) training is included in the induction and mandatory training programmes for clinical staff. Tissue Viability Pressure ulcer reduction collaborative NEAS has been working closely since summer 2014 with regional NHS partners across the North East to see how they can effectively work more closely together towards earlier identification of patients with suspected or actual pressure sores. NEAS is often the first point of contact for many patients to the NHS; therefore they are often the first to encounter patients who are susceptible to pressure area damage. A pressure risk assessment tool has been ratified by PSG and will be piloted in There is a potential for the wider NHS economy to benefit by minimising the risks of tissue damage. Discussions are currently ongoing with North East Pressure Ulcer Collaborative and updates reported through the PSG on a monthly basis. 10. Summary and Conclusion Patient safety remains a priority for the Trust and IPC is integral to maintaining this. The Trust has shown its commitment to IPC by the systems and processes implemented during The key achievements over the year continue to be associated with embedding IPC standards firmly from Board to frontline as demonstrated by audit results, by means of a comprehensive communication plan and joint working between IPC and Operational staff. Key priorities for the coming year are to achieve compliance across all Divisions with the audit schedule to ensure we can provide assurance for practice and environmental domains. Although much has been done on all fronts to continue to drive quality IPC standards to all NEAS staff, to move forward requires the continued support and commitment from the Board to support the IPC team in the delivery of the work plan. Page 19 of 28

20 Appendix A: Infection Prevention & Control Audit Programme Compliance Summary Audit Type IPC Vehicle validation audit Monitoring of scheduled vehicle cleans EC Vehicle Spot Check Target to be achieved 200 vehicles Vehicle compliance 96%-100% Green 90% -95% Amber 89% and below Red Auditor Assurance Compliance with Audit Schedule IPC Report compliance to PSG 65 PTS Vehicles Manager bi-monthly 74 EC Vehicles Total of 139 vehicles IPC Annual audit report audited by IPC manager from April 2016 August All NEAS vehicles MW/GG Report results to PSG EC Vehicles (147 DCA s approx.) ECCMS IPC Annual audit report Report compliance to PSG bi-monthly Annual Report Reported bi-monthly to PSG schedule on track ECCM s completed 154 vehicles audits from observational audit and 82 Vehicle Spot Checks total of 236 EC vehicles Compliance with Policy PTS vehicles cleanliness reported as green above 96% 51% of EC vehicle cleanliness reported complaince as below 89% Cleanliness compliance reported as Green Cleanliness complaince reported as year total 87.6% PTS Vehicle Spot Check and PTS Bare Below the Elbow PTS Vehicles (220 Quarterly 880 Annually) PTS Supervisors IPC Report to PSG Annual Report 458 PTS vehicle were audited achieving 52% compliance with audit schedule PTS Vehicle cleanliness reported as 98% PTS Staff reported as 99% complaint with BBE Premise/Station Cleanliness All stations/premises to be audited once per year Station Compliance Green 95% -100% Amber 90% - 94% Red below 90% IPC Manager IPC Report results to PSG IPC Annual report 50 station audits were completed representing 100% compliance with audit schedule Complaince with IPC station cleanliness; 25 stations Green 18 staitons Amber 7 stations Red Page 20 of 28

21 Station Audits Premises/Station Cleanliness Observational Audits of Practice including Hand Hygiene ANTT BBE PPE All stations monthly 50 stations x 12 = 600 All stations will have cleaning monitored in each quarter All staff observed at least once per annum 1600 EC Staff SSO s IPC Reports to PSG 306 SSO Station Audits have been completed 60 paper (pre June 2016) and 246 electronic. This would represent 51% compliance with audit schedule Cordant ECCM s 55 ECCM s (20 part time) Reporting to IPC monthly to PSG IPC Annual Report Reporting to IPC to monthly PSG IPC Annual Report Cordant have provided evidence of all stations monitored quarterly in Observational Audits submitted by 38 ECCM s The overall year compliance with cleanliness is reported as 85.% Monitoring scores provided by Cordant are Green Compliance Year total for Hand Hygiene = 95% ANTT reported as 100% compliance for 3 rd and 4 th quarter (from Sept 2016 March 2017) BBE year total reported as 94%complaint EC staff not wearing alcohol gel is issue of poor compliance PPE year total reported as 80 % EC staff not wearing aprons idenited as poor complaince Page 21 of 28

22 Sharps / Clinical Waste All stations audited monthly SSO s Reporting to ECCMs IPC report results to PSG IPC Annual Report Sharps and Clinical waste audits included in SSO s and IPC Station Audits totals 356 audits completed in representing 59% compliance with aidit schedule. Compliance with Clinical Waste policy has not been identified from the station audits as poor compliance however drilling down of audit data requires more data repository and IPC input Page 22 of 28

23 Appendix B: Infection Prevention & Control Programme The programme identifies the Infection Prevention Control (IPC) activities that the Team will focus on for the coming year. Page 23 of 28

24 Action Timescale Responsibility 1. IPC policies and procedures are up to date and available for staff. Review IPC section on the intranet in line with current evidence base Ongoing IPC Manager 2 Infection Control Champions provide role model for staff Agree roles and responsibilities for IPC Champions April July 2017 IPC Manager Operational Clinical Service Managers Create a database of champions Provide communication channel for IPC Champions Provide up to date training materials for champions 3. Education and Training To maintain and increase compliance of Mandatory & Statutory to over 95%. To increase compliance of Induction training to 95% Update IPC training materials As and when required Infection Control Manager & Educational & Development team Page 24 of 28

25 Attend monthly meetings across all divisions with Emergency Care clinical Managers Monthly 4. Audits IPC Audits will monitor IPC policy and practice 5. New builds and refurbishments IPC Audits will monitor standards of cleanliness of equipment and environment Data collection / reporting to be electronic IPC Dashboard development See Audit Plan for Estates and Facilities to ensure the Infection Control Team are informed of and involved in the development and planning to ensure all standards are met 6. Staff Health and Safety Increase compliance of point of use disposal of sharps through education and training. Respond to incidents with investigation. June 2017 June 2017 As required Ongoing IPC Team ECCMs SSO s Informatics /IPC Team IPC Manager & Estates & Facilities Team IPC Manager & Risk Team Page 25 of 28

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27 Appendix C: IPC Audit Programme Audit Type Target to be achieved Auditor Assurance Vehicles validation audit at emergency departments 200 vehicles Infection Prevention and Control Manager Report results to PSG IPC Annual audit report PTS Vehicle Cleanliness Audits 220 per quarter PTS Team Leaders Report to PSG Emergency Care vehicle Cleanliness Audits 200 per quarter ECCM s Report to PSG Premise/Station Cleanliness All stations/premises to be audited once per year Infection Prevention and Control Manager IPC Report results to PSG Station Cleanliness All stations will be audited once every quarter SSO s PSG Premises/Station Cleanliness All stations will have cleaning monitored in each quarter Cordant Reporting to IPC monthly to PSG IPC Annual Report Observational Audits of Practice Hand Hygiene PPE ANTT Peripheral Cannulation All staff observed at least once per annum ECCM Reporting to IPC monthly PSG IPC Annual Report Sharps / Clinical Waste All stations audited monthly SSO s Reporting to ECCMs IPC report results to PSG IPC Annual Report Page 27 of 28

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