Annual Work Plan 2009 2010 Final Report Highland NHS Board 10 August 2010 Item 4.5(a) 1.1 To reduce all staphylococcus aureus bacteraemia (including MRSA) by 30% by 2010. 1. Local Delivery Plan - HEAT Targets There have been 73 Staph aureus bacteraemia cases in the period April 2009 to end March 2010. The target was 54 cases. Since January 2010 a Root cause analysis is undertaken on each SAB. This is reported to the NHS SAB Action Group for monitoring and identification of trends. The action group is meeting twice a month. The purpose of which is to ensure the action plan is fully implemented by all staff and changes are made to improve practice and reduce the risk of infection. NHS Highland staff are following the QIS Infection Improvement &Implementation Programme (iiip). which is fully aligned with the Scottish patient safety programme (SPSP). March 2010 Red 1.2 Reduce the number of Clostridium difficile cases by a minimum of 30% by March 2011. Progress against the plan is reported in the bimonthly Board HAI report. NHS Highland is on target to meet this objective. During April08- March 09 there were a total of 183 Clostridium difficile cases.( Argyll and Bute figures were added from January 2009) April 2009 March 2010 there were 147 cases March 2011
1.3 Reduce rates below 1 case of Clostridium difficile associated disease per 1000 total occupied bed days in patients aged 65 and over. 1.4 Monitor compliance with agreed supporting antimicrobial prescribing indicators. The number of cases in the age group 65 and over for the period October December 2009 was 19( 0.37 per 1000 total /Acute bed days) The total number for Scotland for the same period was 672 ( 0.52 per 1000 total/acute bed days) NHS Highland Antimicrobial Management Team monitors antimicrobial prescribing in terms of preferred antibiotics compared with CDI associated antibiotics and restricted agents. Ceftriaxone prescribing remains at low levels in Raigmore, Caithness General and Belford with prescriptions monitored. Data is awaited from NHS GGC. Point prevalence audit results comment on appropriate use of high CDI risk drugs. Data collection continues for the Scottish National Audit Project for Community Acquired Pneumonia (SNAP-CAP) Management of Infection Guidance sections continue to be updated on a rolling basis. Reviewed in 2009/10 surgical prophylaxis and respiratory tract infection. Reviewed treatment of diabetic foot infections, ands skin and soft tissue infections. March 2011 March 2011 Infection Control / Alison MacDonald, Antimicrobial Infection Pharmacist Under review at present include the treatment of systemic and other infections such as osteomyelitis, and sections on Antibiotic prophylaxis for Surgery. 2
Education on Antimicrobial prescribing Educational opportunities at audit feedback sessions are used to highlight areas where prescribing could be improved. Enhanced surveillance of patients with CDI is highlighting areas where further training is required for the prescription and use of antimicrobials 2. Corporate Objectives 1.5 Increase the uptake of MMR Vaccine to achieve national targets of 95% 2.1 Making Everybody s business - Support and develop processes and structures in the CHP s to promote local control of infection. Now over 95% at aged 5 years The Control of Infection Committee (COIC) reports to the Board via the Clinical Governance Committee. COIC terms of reference were revised in December 2009. The terms of reference of the Professional Advisory Group were subsequently revised to enhance the operational delivery of the infection control agenda with the name changed to Implementation Group Each CHP/Raigmore Infection Control Group provides feedback to the CHP/Raigmore committees and to the Implementation group Heidi May Board Nurse Director/ Nurses 3
2.2 Maintain a low level of post operative surgical site infections (SSI) in line with National Targets The cumulative incidence (number of SSIs per 100 procedures ) of all caesarean section procedures until day 10 post operatively, from April to December 2009 showed that NHS Highland at the confidence limit of 95% The action plan developed focuses on surveillance, peri and post operative care, clinical practice and implementation of national guidance. Ongoing Hip Arthroplasty procedures in 2009 were within the 95% confidence limit for SSIs detected by readmission until day 30 post operatively 2.3 Maximise the use of isolation facilities available in NHS Highland and increase isolation facilities where appropriate for the safe care of infectious patients. Surveillance on Abdominal Aortic Aneurysm, Total Abdominal Hysterectomy and Total Knee Replacement were discontinued in October 2009 to fulfil the requirement to collect data on Emergency Caesarean sections for the mandatory programme. Where possible, offices in the ward areas have been returned to clinical use and converted into single accommodation. Belford Hospital built an isolation room. Where this is not possible to provide single accommodation, contingency plans have been put in place. March 2010 Douglas Seago / Nurses 4
2.4 Ensure each ward and department has a named Cleanliness Champion. 2.5 Ensure appropriate widespread availability of hand hygiene products. 2.6 Undertake and monitor structured cleanliness surveys of clinical areas with Patient / Public representatives and publish feedback reports. 2.7 Review / standardise all Infection Control patient and public information leaflets and posters in accordance with PICT strategy. The majority of wards / departments have a named Cleanliness Champion. According to NES statistics 148 Band 7 Staff in NHS Highland have registered of which 88 have completed 49 as yet have no outcome and 11 have withdrawn as at 24 th March 2010 Hand Hygiene Products are available in all areas. A regular programme of audits is undertaken involving patient /public representatives. Feedback is provided to patients Councils and Patient /Public involvement groups. HPS nationally produced public information leaflets are used. Where there is a gap the ICT develop leaflets in accordance with the Written Information for Patients Policy. All ICT patient and public information leaflets and posters are available on the intranet. September 2009 Nurses Nurses Douglas Seago Head of Facilities Team 2.8 Develop and implement an action plan in respect of the NHS Highland Clostridium difficile gap analysis (Vale of Leven Review) NHSH are on track to meet Cdiff target and are fully engaged with the Antimicrobial prescribing agenda. The HEI audit tool and inspectorate process has been adopted throughout NHSH. July 2009, / Infection Control Manager 5
3. Monitoring care Associated Infection 2.9 Ensure learning approach to events and incidents both locally and nationally is achieved. 3.1 Continue surveillance of ITU infections, including CVC and Ventilator-associated pneumonia. A learning approach to outbreaks/incidents of communicable infection has been adopted. A review of performance and learning points takes place. An example is following the Norovirus outbreak at Raigmore Hospital. The total number of cases in the period April 2009 March 2010 are as follows:- Ventilator Associated Pneumonia -4 CVC related -1 Ongoing Senior managers/infection Control Team The Scottish Intensive Care Society Audit Group (SICSAG) is now in collaboration with Protection Scotland (HPS). Their first national report is due in June 2010. 3.2 Continue participation in national surveillance schemes, to SPSP and HPS requirements including:- Staph aureus bacteraemia Surgical Site Infection (including post-discharge surveillance) Outbreak Surveillance Clostridium difficile infection SICSAG provide a monthly spreadsheet to ITU including all data collected from the ward watcher system which includes data required from the Scottish Patient Safety Programme(SPSP) Participation in the national schemes continues SSI surveillance includes 10 days post discharge emergency c. section procedures. Feedback on Staph aureus bacteraemia and Clostridium difficile infection is distributed weekly. 6
3.3 Maintain Alert Organism surveillance programme. 3.4 Reduce post elective caesarean section infection rates. 3.5 Install the national electronic recording system of surveillance data (ECOSS). 3.6 Develop HAI trigger levels/alerts and a standard operating procedure for all hospitals pan Highland. 3.7 Review HAI monitoring information and distribution of reports. Alert organism surveillance continues Cases recorded are reported in the bi-monthly Board report There were 19 elective caesarean section infections in Raigmore hospital this year. A revised action plan is in place A Theatre review has been undertaken in Caithness General Hospital There have been no cases in Caithness General Hospital this year ECOSS installation has been completed. Trigger levels have been developed for CDI and SABs for all hospitals in NHS Highland Reports are reviewed on an ongoing basis. The weekly HAI reports continue to be revised to provide more information on all hospitals in Highland. Distribution lists are constantly reviewed to ensure the correct information reaches staff. Senior Charge nurses are encouraged to use this information to change and improve practice September 2009 Head of Midwifery / Nurses December 2009, / E- May 2009, May 2009, 7
4. Decontamination and Sterilization 4.1 Support and monitor progress towards ensuring Glennie Technical requirements in Primary Care settings. HDL (2006) 40 Capital and revenue investment has been made to ensure the managed services in the Mid, South- East and North CHPs will have compliant facilities Services in Argyll and Bute will be compliant in line with the SGHD revised timescale June 2010 Douglas Seago, Head of Facilities December2011 Douglas Seago 5. Enhanced Environmental Cleaning 5.1 Undertake an annual de-cluttering programme of all hospitals in Highland. 5.2 Implement the use of Steam Cleaning Kits in hospital facilities. 5.3 Monitor expenditure of new funding from Scottish Government for additional cleaning staff and ensure improved outcomes. De-cluttering of wards is carried out on an ongoing basis. The Environmental audits pick up on any issues which the Senior Charge Nurse is expected to respond to. 16 Steam Cleaners have been distributed throughout Highland. The Domestic staff are being taught how to use the cleaners which are used as an additional tool to remove debris on some surfaces and equipment. Additional funding has been provided by the Government for approximately 22 WTE Domestic staff throughout Highland. Recruitment is almost complete. Each area has identified how the resource will be used to gain maximum benefit, for example increasing the cover of Domestic staff out of hours and at weekends, creating Estates Maintenance posts to clean radiators and light fittings etc and creating a cleaning Hit Squad March 2010 nurses Douglas Seago, Head of Facilities March 2010 Douglas Seago, Head of Facilities / Manager 8
6. Immunisation 6.1 Oversee the work of Highland Immunisation Co-ordinating Group (HICOG) 6.2 Co-ordinate implementation of the national Childhood vaccination Programme. 6.3 Implement the new HPV vaccination programme. 6.4 Develop a Mass Vaccination Plan for the local population. 6.5 Achieve 70% uptake of seasonal flu vaccine in those aged 65 and over. 6.6 Preparation for mass swine flu Immunisation of whole population. 7. Policy Reviews 7.1 In conjunction with the Antimicrobial Management Team and the antibiotic prescribing pharmacists review pan Highland the antimicrobial prescribing policy and oversee implementation. Work was superceded this year by the H1N1 Vaccination Group. All programmes successfully delivered throughout the year with higher than ever uptake rates Year 2 successfully delivered with over 90% uptake over all Ongoing, progress hindered by swine flu outbreak March 2011 Achieved November 2009 - March 2010 Completed vaccination campaign of high risk groups The following sections have been reviewed Treatment of respiratory tract infection, urinary tract infections, surgical prophylaxis, treatment of adult oncology/haematology patients with febrile neutropenia and treatment of meningitis October 2009 Alison MacDonald Antimicrobial Pharmacist 9
Review and update the following policies:- A wide range of staff are invited to comment when reviewing and updating policies. Transmission Based Precautions.Completed February 2009 May 2009 (Source Isolation) Immunisation Procedure Completed September 2009 September 2009 MRSA Completed December 2009 September 2009 Food Hygiene (Ward Level) Completed November 2009 September 2009 Hand Hygiene Policy Completed August 2009 September 2009 Outbreak / Incident Management Completed June 2009 September 2009 Policy (including incidents with Medical Devices) Decontamination Policy Out for comment September 2009 Managing Infections During Last Offices Management of Blood and other Body Fluids Spillages Completed January 2010 September 2009 Completed December 2009 September 2009 Tuberculosis Out for comment September 2009 Disposal Policy Waste Out for comment September 2009 Insertion and Maintenance of Central Venous Catheters Completed July 2009 September 2009 Legionella Completed December 2009 October 2009 10
Personal and Protective Equipment Out for comment November 2009 Policy Control of Environment Policy Out for comment November 2009 Needle Stick Injury Policy Completed May 2009 November 2009 Guidelines for preventing infections Out for comment December 2009 associated with the insertion and maintenance of short term indwelling urethral catheters. Care of Equipment Policy Out for comment March 2010 8. Pandemic Flu 8.1 Maintain and exercise an NHS Contingency Plan for Pandemic Influenza in line with national guidelines. 8.2 Continue to update preparedness plans in respect of pandemic / swine flu 9. Education 9.1 Identify Key Performance Indicators in respect of the Education/Training Programme and implement reporting mechanisms. The real swine flu pandemic replaced any need to have an exercise. Plans were developed significantly throughout pandemic. Now will be updated further in light of all lessons learned Key performance indicators have been set for the delivery of education on the following : Reduction of staph aureus bacteraemias by 2010. Reduction of Clostridium difficile infection by 2011. Achievement of a minimum compliance rate with hand hygiene of at least 90% Ongoing September 2009, / Infection Control Implementation Group. The reporting mechanisms is through the management structures and the bimonthly report 11
9.2 Develop a strategy for CPD in relation to Hospital Associated Infection in accordance with Code of Practice for Local Management of Hygiene and Hospital Associated Infection. Mandatory HAI training requirements reviewed and agreed. This is now being converted into policy. HAI training now incorporated into the Charge Nurse Development Programme. September 2009 Team 9.3 Ensure HAI specific elements are included in all staff KSF outlines/pdp. 9.4 Support and roll out education programmes including Link Nurse training Cleanliness Champions Mandatory induction training in infection control. Hand Hygiene Policies 9.5 Develop and implement a formal evaluation system in respect of all education sessions. This is being progressed as part of the annual review and PDP process. Deloitte & Touche Auditors have been conducting an audit to establish whether all staff has HAI objectives in their PDPs and what these are. There have been problems with internal audit getting access to PDPs as staff have been reluctant to share this information. Alternative methodology agreed and has been implemented. Education programmes have been implemented pan Highland offering training to staff on a range of subjects relating to Infection control. Ad hoc training sessions are provided on request ( can be one to one, groups, ward /department based) Link Nurse meetings are held regularly and include education sessions. Feedback questionnaires are issued to participants at training sessions and the content amended to reflect feedback May 2009 Nurses / Allied Professionals / Clinical Directors September 2009 Team 12
10 Audit 10.1 Develop, support and monitor progress of NHS Highland infection control audit programme. NHS Highland infection control; audit programme has been completed. The focus has shifted from environmental audits to clinical audits such as Root Cause Analysis outcomes, PVC/CVC compliance. February 2010 10.2 Take part in the National Hand Hygiene campaign using audit results to improve local compliance. Achieve National Target of at least 90% compliance. NHS Highland compliance rate is 94% as at March 2010 The Hand Hygiene action plan is monitored through the Hand hygiene Action group and the Control of Infection Committee. Pat Tyrell. Chair of Hand Hygiene Action Group The Zero tolerance policy for non compliance with hand hygiene has been developed and is supported through the HH group ensuring improvement, education, audits and appropriate use of products. 11 Advice and Support 11.1 Provide on-going advice and support During Critical incidents and Outbreaks. To Incident Control Team. On going advice and support continues to be provided as required such as the SAB action plan group, and Norovirus outbreaks 13
12 Public Information & Involvement 13 Development of Service for NHS Highland 12.1 Set out arrangements for fulfilling the key roles of the Information Officer: Provide a visible, accessible contact point for public HAI information. Co-ordinate production and distribution of public HAI information in accordance with emerging standards and policies. Provide the key link between NHS Highland and the patients/public to establish their information needs. 12.2 Provide training sessions for Patient/Public representatives participating in the National Cleaning Specification Audits. 13.1 Work towards full integration of Argyll & Bute Services, procedures and structures including work of audit programmes. 13.2 Monitor resourcing of Infection Control in NHS Highland, taking account of proposed service developments, to ensure that it is adequate to meet demand. Internet access for the public has been established via NHS Highland web site. Further work is ongoing to make the HAI information more user friendly and easier to understand. Public HAI information has been reviewed and standardised. see 2.7 Work is ongoing to strengthen the link between NHS Highland and the patients/public with regard to HAI information needs. All patients /public representatives participating in the monitoring of cleaning standards are given training on the NHS Scotland Cleaning Specification Clear governance arrangements are in place. Argyll and Bute Infection Control team are part of NHS Highland Team and as such follow the same policies, procedures and audit programmes. NHS Highland have not yet been successful in recruiting a Clinical for Argyll and Bute. Resources are regularly reviewed taking into account service requirements. An example of this is focussing and increasing surveillance on Cdiff and SABs by reducing environmental surveillance ( now carried out by HEI style teams) and by ITU staff taking ownership for ITU surveillance Manager Douglas Seago Head of Facilities Heidi May, Board Nurse Director Pat Tyrrell, Nurse Argyll & Bute, Manager 14
13.3 Review current arrangements for access by all CHP s / Raigmore to ICT policies and service information and make more robust. 13.4 Ensure secretarial support is available to all Teams across NHS Highland. All polices are available on the Intranet and are updated on a rolling programme by the IC team. There are hard copies in selected sites which are updated regularly by the IC team The system for notifying staff of policy updates has been reviewed, the effectiveness of which requires to be audited. October 2009 Manager Secretarial support is available within resources. July 2009 Nurses 14 Scottish Government Policy 13.5 Review the Governance Structure 14.1 Implement an action plan to meet requirements of the QIS HAI Standards. 14.2 Respond to and co-ordinate local implementation of any new national policy and guidance as per the HAI Task Force Delivery Plan 2008 2011. 14.3 Complete the mandatory on-line HAI Self Assessment in respect of The care Environment Inspectorate Scotland. The Control of Infection Committee now reports through the Clinical Governance and Risk Management Committee and also directly to the Board Relevant actions have been embedded into Raigmore/ CHP Groups/SAB Action Group/ Hand Hygiene Group/ Implementation Group and the Annual Work Plan. Response and co-ordination of local implementation of any new national policy and guidance is ongoing and is monitored through ICIG On Line self Assessment completed June 2009 Heidi May, Board Nurse Director July 2009 Manager Manager/ Infection Control June 2009 Manager / Andrew Hay, Infection Control 15
14.4 Participate in the national programme of inspections by The care Environment Inspectorate Scotland. Develop and implement an action plan for any actions identified by that process. HEI Inspectorate visit to Raigmore Hospital 15 th & 16 th December 2009 Subsequent Action plan in progress HEI visit to Caithness General Hospital 8 th &9 th July 2010 Infection Control / Manager 15 Report to the Risk Management and Clinical Governance Committee and as appropriate to the NHS Board 15.1 Prepare Annual Report 15.2 Copies of Minutes and Annual Report to the Clinical Governance Committee End of year Report submitted to the Board. Interim progress report submitted to the Board in December 2009 End of year Report and COIC minutes submitted to the Clinical Governance and Risk management Committee April 2009 Manager Manager Key Red Complete On track to complete by the deadline Substantially complete but either awaiting national materials or with some possibility of slippage beyond the deadline Unable to complete by the deadline 16