Tom Walsh Infection Control Manager May 2008 ANNUAL INFECTION CONTROL REPORT 2007/08

Tom Walsh Infection Control Manager May 2008 ANNUAL INFECTION CONTROL REPORT 2007/08

CONTENTS 1. INTRODUCTION... 1 2. ACCOUNTABILITY ARRANGEMENTS FOR PREVENTION & CONTROL OF INFECTION WITHIN NHSGGC... 2 Appendix A... 3 Appendix B... 4 3. RISK MANAGEMENT ARRANGEMENTS... 5 4. PROGRESS AGAINST THE KEY OBJECTIVES IN THE 2007/08 INFECTION CONTROL PROGRAMME... 6 4.1.1 MRSA BACTERAEMIAS... 6 4.1.2 HAND HYGIENE... 6 4.1.3 SURVEILLANCE... 7 4.1.4 EDUCATION INCLUDING CLEANLINESS CHAMPIONS... 7 4.1.5 INFECTION PREVENTION & CONTROL POLICY... 8 4.1.6 DECONTAMINATION OF RE-USABLE MEDICAL DEVICES... 8 4.1.7 CLEANING SERVICES... 9 4.1.8 PUBLIC INVOLVEMENT... 9 4.1.9 PUBLIC HEALTH... 9 4.1.10 HAI PREVALENCE... 10 4.1.11 ANTIMICROBIAL MANAGEMENT TEAM... 10 5. 2008/09 INFECTION CONTROL PROGRAMME... 11 6. GLOSSARY.... 12

1. INTRODUCTION This report outlines the activities of NHS Greater Glasgow and Clyde relating to Infection Prevention and Control during 2007/08. The primary purpose of the report is to review and document progress against the NHS Board Annual Infection Control Programme. The report also depicts the accountability and risk management arrangements relating to Infection Prevention and Control within NHSGGC. Prevention and control of infection has always had a high priority within NHSGGC and the Board Infection Control Committee (BICC) has developed and implemented a challenging programme of work during 2007/08. The programme addressed NHS Scotland National Programmes and Mandatory Requirements together with key priority areas identified in the HEAT Targets by the Healthcare Acquired Infection (HAI) Task Force and Quality Improvement Scotland (QIS). The BICC relies on and acknowledges the work of all the disciplines who come together to promote good practice in Infection Prevention and Control. Central to these efforts and achievements are the detailed work plans and actions of the local Infection Control Committees and Infection Control Teams. Good practice in Infection Prevention and Control clearly does not rest solely within the domains of our Infection Control Committees and Teams. Everyone has Infection Prevention and Control responsibilities. Service users who depend on NHSGGC require all of us to follow best practice as described in the NHSGGC Infection Prevention and Control Manual www.nhsggc.org.uk/infectioncontrol. Tom Walsh Infection Control Manager NHS GREATER GLASGOW AND CLYDE 1

2. ACCOUNTABILITY ARRANGEMENTS NHS Greater Glasgow and Clyde Infection Control Structure Scottish Government Health Department (SGHD) NHS Greater Glasgow and Clyde Chief Executive Nurse Director Medical Director Director of Public Health Risk Management Group Board Clinical Governance Committee Board Infection Control Committee Infection Control Manager Partnership Infection Control Committee Acute Infection Control Committee Nurse Consultant Infection Control Partnership Infection Control Team Acute Infection Control Team Areas of responsibility See Appendix A Areas of responsibility See Appendix B 2

Appendix A Areas of Responsibility Partnerships Prevention & Control of Infection Team Community Health & Care Partnerships - East - North - South - South West - South East - West - West Dunbartonshire - East Dunbartonshire - Inverclyde - Camglen - Renfrewshire (Please note a service is not provided to GP practices, GDP not within the managed or salaried services or social care staff). Partnerships - Mental Health - Addiction - Homeless - Learning Disability This includes all Resource Centres, Day Hospitals and the In-Patient Sites at: - Gartnavel Royal Hospital - Parkhead Hospital - Stobhill Hospital: McKinnon, Armadale, 43 & 44 - Dykebar Hospital - Ravenscraig Hospital - Leverndale Hospital - Rowanbank Unit - Mearnskirk - Southern General Hospital: 31, 32 & peri-natal - Orchard at Ruchill Hospital Others - Sandyford Initiative and Hubs - Community Breast Screening Services including the mobile services - Oral Health Toothbrushing Initiative Glasgow Dental Hospital - Floor 1 3

Appendix B Areas of Responsibility Acute Prevention & Control of Infection Team General Manager Infection Control Co-ordinating Doctor Laboratory Medicine x 2 Infection Control Manager Head Nurse Infection Control Nurse Consultant Infection Control Lead ICN South Glasgow Lead ICN NE Glasgow Lead ICN NW Glasgow Lead ICN Clyde Lead ICN Mat / Paeds Senior ICN Senior ICN Senior ICN Lead Surveillance Nurse Senior ICN Senior ICN ICNs ICNs ICNs Surveillance Nurse Data Manager ICNs ICNs Managerial Line Operational Line 4

NHS Greater Glasgow and Clyde Risk Management Process for Infection Prevention and Control Infection Control Risk Register Escalation / Communication Flow NHSGGC Corporate Risk Register Directorate RR Escalation Process via AS Management Group NHSGGC Board Clinical Governance Committee NHSGGC Board Infection Control Committee Partnerships RR Escalation Process via Directors Group Diagnostic Directorate Board Acute Infection Control Committee (AICC) Partnerships Infection Control Committee (PICC) CHCPs & Mental Health Partnerships Local ICTs develop Risk Registers This diagram illustrates the application of the NHS Board Risk Management Policy within the Infection Control Service During this year development of infection control risk registers commenced, with good progress made in both Acute and Partnerships. The above structure demonstrates the links between infection control and risk management to the rest of the organisation. This structure ensures that relevant risks are communicated both within the infection control structures and also to the wider clinical community for inclusion in their risk registers. A link Clinical Risk Manager was appointed to Infection Control from the CGSU to provide support at Acute and Board level on clinical risk issues. Work has also been undertaken in developing Infection Control reporting categories within the new incident reporting codes in preparation for Datix Risk Management System implementation, eg CJD and decontamination. 5

4. NHSGGC PROGRESS AGAINST KEY OBJECTIVES IN THE 2007/08 INFECTION CONTROL PROGRAMME 4.1 Healthcare Efficiency and Access to Treatment target (Reduction of Staphylococcus aureus bacteraemia by 35% by 2010) This is the first year of a three-year programme and during the year the focus has been on collecting data and evaluating different feedback mechanisms. Several strategies are currently being employed / evaluated. Infection Control Teams across the Board area are collecting enhanced data (using a data collection form developed by Health Protection Scotland) in order to target not only areas with a high prevalence but also interventions associated with the acquisition of bacteraemia, eg central venous catheterisation. In addition, Statistical Process Control Charts have been introduced into all clinical areas, with the aim to return information to those with the ability to change clinical practice. Reducing the incidence of Meticillin Resistant Staphylococcus aureus (MRSA) should intuitively reduce the numbers of MRSA bacteraemia. NHSGGC is committed to quality improvement in infection control practice and is actively promoting the implementation of the newly developed Health Protection Scotland (HPS) Care Bundles especially those specifically designed to optimise care with regard to the insertion and maintenance of both centrally and peripherally inserted venous catheters. An example of how this translates into practice, is the development of the West of Scotland cancer nurses (WOSCAN) initiative which has its central theme the utilisation of Care Bundles. These bundles are part of the Institute of Healthcare Improvement (IHI) methodology that also underpins the NHS Scotland Scottish Patient Safety Programme. This example of good practice is being shared with other key staff groups including colleagues in critical care and renal medicine. Indeed the production of the NHSGGC Central Venous Catheter Care Policy is being positively influenced by this and will include the elements contained within the WOSCAN initiative. This policy will ultimately be used by all staff within NHSGGC who insert or maintain CVCs. Links to the care bundles are also available via the NHSGGC website. An educational package detailing the principles and use of the care bundles is currently being developed and will be available online to all staff within NHSGGC. NHSGGC is currently ahead of trajectory and will continue to focus on this priority area in 2008/09 and 2009/10, to continue progress towards the 35% target. 4.2 The Scottish National Hand Hygiene Campaign The Campaign was launched in January 2007 with the aim of improving hand hygiene compliance amongst NHS staff and providing education and reinforcement to the public. Local Health Board Co-ordinators (LHBC) are employed in all of Scotland s Health Boards to implement the key aims of the campaign. Audit Activity Audits commenced in February 2007 with the focus on key areas in acute sites based on previous prevalence data. 115 wards were audited for compliance in 2007/08 a total of 2460 staff contacts were recorded in the audits any staff member present on the ward at that time is subject to the audit 20 opportunities for Hand Hygiene are recorded, based on World Health Organisation guidelines for contacts within the Acute setting the results are immediately given to ward management verbally written reports are then compiled and sent to Lead Nurses and Infection Control Leads for distribution the figures also contribute to the Ward Profiles 6

During the National Audit Periods in February 2007, September 2007 and February 2008, the results were compiled for all Scottish Boards by Health Protection Scotland and form part of a National Report. This can be viewed at http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=36570 Greater Glasgow and Clyde reported a rise in compliance from 62% in February 2007 to 82% in September 2007. The 3 rd National Audit in February 2008 showed that overall compliance was 83%. SGHD have set NHS Boards a target of 90% compliance by November 2008. Hand Hygiene will continue to be a key component of the 2008/09 Infection Control Programme. 4.3 Surveillance National Programmes and Mandatory Requirements HDL (2006)38 sets out NHS Scotland s responsibility in relation to Surveillance of Healthcare Associated Infection. NHSGGC currently returns data to Health Protection Scotland on the following: Meticillin resistant S aureus bacteraemias (MRSA) Meticillin sensitive S aureus bacteraemias (MSSA) Numbers of stool specimens positive for Clostridium difficile Surveillance of Surgical Site Infection in all hip arthroplasties, elective total knee replacements and caesarean sections Surveillance to day-30 post-operation is now mandatory and although this is in place for all of the orthopaedic procedures, the implementation of this with regards to caesarean section procedures has been problematic. The NHSGGC surveillance team is working closely with HPS to resolve this issue. During 2007/08 the Acute Operating Division Surveillance Team have fully integrated across NHSGGC, and single-system structures and processes are now in place. 4.4 Education / Cleanliness Champions (CC) The Cleanliness Champions Programme was introduced by NHS Education Scotland in 2002. NHSGGC was asked to facilitate the training of 983 CCs, a target that was exceeded in March 2008. This target required a significant investment in time and resources and the priority for 2007/08 was to provide a structure to support the ongoing education and commitment of the CC and link this to other HAI initiatives, eg Scottish Patient Safety Programme, QIS HAI Standards. During 2007/08 the Department of Learning and Education (L&E) conducted a review of the current provision of corporate induction training. In the past this induction was site specific and delivered in a didactic format. The elements of induction will now be delivered via the Learning and Education Portal. In order to complement this methodology and to facilitate other types of online education for staff, the Infection Control Education Sub-Group developed and agreed a single Infection Control Induction Framework, which will link to the L&E portal. Facilitating e- learning was a priority in the 2007/08 Programme and not only this but an additional 10 education modules, including, Hand Hygiene, MRSA, C difficile, were developed and will be online via the NHSGGC website by 31 May 2008. All e-learning via the Infection Control Site will be tracked and information returned to local clinical teams and to L&E. Access to this system can be obtained from a clinical area or from home. This will make Infection Control Education more accessible to staff throughout NHSGGC. Infection Control Teams continue to deliver education on many subjects as required via Practice Development. Education is also provided to all of the Universities in NHSGGC. 7

4.5 Infection Prevention and Control Policies NHSGGC has a comprehensive, single approved manual of Board-wide policies. The updating / development of policy documents are currently as per the agreed review schedule. During 2007/08 several new policies have been developed and ratified by the BICC including: Update Outbreak Policy NEW Antibiotic Policy NEW Staff Screening Policy NEW Loose Stools Policy NEW Terminal Clean of an Isolation Room (SOP) NEW Daily Clean of an Isolation Room (SOP) NEW Norovirus Policy (Final Draft) NEW Whooping Cough (Final Draft) UPDATE MRSA Policy (First Draft) In addition, several of the Patient Information Leaflets (PILs) have been updated and four new additional PILs have been developed. In accordance with the requirement of the Code of Practice (CoP) five of the most frequently requested PILs have been translated into five commonly spoken languages, and have also been converted into formats which should make them more accessible to the sensory impaired. All of the IC Policies and PILs are now available on the internet at www.nhsggc.org.uk/infectioncontrol. 4.6 Decontamination of re-usable Medical Devices Central Decontamination Unit The Central Decontamination Unit at Cowlairs achieved ISO13485 accreditation in August 2006. All high-risk instruments are currently processed through the accredited units in Glasgow and Inverclyde. The following Acute Hospitals have now transferred into the new Unit: Stobhill Hospital Yorkhill Hospital Victoria Hospital Final plans are in place to transfer Gartnavel General Hospital, Glasgow Royal Infirmary and the Southern General Hospital. A number of specialties within the Southern General and Glasgow Royal have already transferred into the Unit. Decontamination in Primary Care All decontamination (Primary Care Audit Tool (PCAT)) audits have now been completed. An Implementation Group, chaired by the Director of Facilities, has been set up, and a project manager appointed to progress the decontamination agenda with primary care and oral health. Action plans have been produced and returned to SGHD in Nov 2007. A feasibility study of directly managed units was completed in Feb 2008. This formed part of a full options appraisal which recommends new central decontamination facilities for Primary Care services. Work continues with directly managed services, independent contractors and General Dental Practitioners (GDPs). Decontamination of Flexible Endoscopes A BICC Sub-Group, chaired by the Director of Facilities, oversees the implementation of the draft HPS Technical Requirements for the processing of flexible endoscopes. 8

A range of investment options have been evaluated and planned for the Acute Sites within NHSGGC with Glasgow Royal Infirmary and Southern General Hospital Institute of Neurological Sciences being the first sites to be re-modelled. Included within the overall programme is the introduction of a robust tracking and traceability system. In addition, a staff training centre has been established at Cowlairs jointly funded by NHS Education Scotland (NES) and NHSGGC. 4.7 Cleaning Services In the published results for the National Cleaning Specification and National Monitoring Framework, NHSGGC has consistently scored green within the Framework. The current focus is on continuous quality improvement initiatives to improve all scores to a minimum level of 95% within the Board. Other initiatives implemented during 2007/08 include: increasing the frequency of peer/public reviews to levels above those recommended encouraging public involvement and providing structured training and feedback sessions development of an Infection Control Booklet for domestic services implementation of the National Domestic Supervisors Development Pack 4.8 Patient Focussed Public Involvement NHSGGC is committed to involving the public in decisions pertaining to the Prevention and Control of Infection and the planning and delivery of the Infection Control Service. In addition to public representation on the Board Infection Control Committee we have recruited members of the public into three key Patient Focus Public Involvement (PFPI) groups: Public and Peer Review of the National Monitoring Framework for Domestic Services. Board HAI Public Information Review Group this group, which is led by the Nurse Consultant Infection Control, reviews information developed to inform patients and the public of HAI issues. This group is also consulted on the implementation of specific HAI initiatives, eg the NHSGGC Prevention and Control of Infection Programme of Work. A member of this group sits on the Board Infection Control Committee. QIS HAI Standards Implementation Group. In addition, the Infection Control Service have over the past six months established links with the Board Lead for PFPI and have participated in several public involvement meetings and initiatives. Links have also been made to the PFPI leads in the CH(C)Ps. In 2008/09 we hope to develop and strengthen these links with the wider PFPI community and develop strategies to communicate infection control information throughout NHSGGC. 4.9 Public Health There have been a number of high-profile public health incidents during the year 2007/08. One of the high-profile incidents involved an outbreak of e-coli O157 in Paisley. The public health department worked closely with Renfrewshire Council and other colleagues including clinical and laboratory staff from the Royal Alexandra Hospital. In total, ten cases were affected, with one fatality. The public health department submitted a report to the procurator fiscal in Paisley, who is currently considering the possibility of undertaking a fatal accident enquiry. There was also a high-profile outbreak of salmonella linked with a restaurant in the Balloch area, again public health worked very closely with the local authority and healthcare staff both from the hospital and the community in managing this outbreak. 9

There have also been widespread outbreaks of diarrhoea and vomiting due to norovirus both in the hospitals and in the community. In view of the anxiety created by the national and local media coverage of these outbreaks, the communications team in NHS Greater Glasgow and Clyde set up a special web broadcast produced by the department and the broadcast issued key advice to residents on helping to tackle the virus in both the community and in healthcare settings. Public health continues to work very closely with both NHS and local authority colleagues in implementing various prevention programmes and also to respond to various incidents and outbreaks as and when they occur. 4.10 HAI Prevalence Study This study was conducted by Health Protection Scotland in 2005/06 and was published in July 2007. The study acknowledged that the results were unadjusted in terms of seasonality and patient mix; however within NHSGGC several areas were identified as having a higher than unadjusted average prevalence of one or more HAI. As a result, resources and arrangements were put in place to repeat the 2005/06 study in these areas and to progress any quality improvement actions identified. Repeat audits demonstrated significant improvement in the clinical areas surveyed. 4.11 Antimicrobial Management Team The Greater Glasgow and Clyde Antimicrobial Management Team (AMT) was formed in May 2007. This group consists of a Lead Physician, Lead Microbiologist and Lead Pharmacist. The AMT reports to the Chairman of the Board s Prescribing Management Group. Its work is supported and guided by a sub-group of the Board-level Area Drug and Therapeutics Committee the Antimicrobial Utilisation Committee (AUC), whose membership reflects the full range of stakeholders with responsibility for prudent prescribing of antimicrobial medicines. Antimicrobial Management Team achievements to date Development and approval of: 1. Infection Management Guidelines (Medicine) 2. Intravenous to Oral Switch Therapy Policy (IVOST) 3. Alert Antibiotic Scheme 4. Accident and Emergency Antibiotic Guidelines 5. Gentamicin Guidelines In process of development: 1. Surgical Sepsis Management Guidelines 2. Vancomycin Guidelines 3. Gentamicin / Vancomycin electronic dosage calculator for doctors / pharmacists Reports Quarterly reports on antimicrobial usage and spend within GGC. Future Four antimicrobial pharmacists should be in place by June 2008. We will then be able to encourage implementation of the above policies and provide audit and feedback to directorates, hospitals, wards etc. Educational need for prescribers, including nurses and pharmacists, in relation to antimicrobials will be identified and training implemented. 10

5. 2008/09 INFECTION CONTROL PROGRAMME The 2008/09 Infection Prevention & Control Programme has been developed and approved at Clinical Governance Committee and Board Infection Control Committee. The Acute and Partnerships Infection Control Teams and Committees have developed detailed local infection control work programmes based on the strategic themes and goals set out in the corporate programme. The overall infection prevention and control work programmes will continue to be implemented and monitored through the NHSGGC infection prevention and control structure and communicated to Clinical Governance and Risk Management on an exception reporting basis. 11

GLOSSARY AICC Acute Infection Control Committee Alert organism alert condition Any of a number of organisms or infections that could indicate, or cause, outbreaks of infection in the hospital or community. All such organisms and conditions should be promptly reported to a member of the infection control team. Bacteraemia Infection in the blood. Also known as Blood Stream Infection. BICC Board Infection Control Committee C. difficile Clostridium difficile also referred to as C. diff (or C-diff) is a Gram-positive sporeforming anaerobic bacteria. C. difficile is the commonest cause of gastro-intestinal infection in hospitals. It causes two conditions; antibiotic associated diarrhoea and the more severe and occasionally life-threatening pseudomembranous colitis. Control of the organism can be problematic due to the formation of spores and difficulty in removing them. Patients who have had antibiotics within the last eight weeks are most at risk of acquisition of the organism. CC Cleanliness Champion A Ministerial led initiative to offer a specific education programme to HCWs. http://www.scotland.gov.uk/topics/health/nhs-scotland/19529/19322 CGSU Clinical Governance Support Unit CHCP CoP CSBS/QIS GDPs HAI HCW HEAT Targets HPS ICN /T /O /D Community Health Care Partnership Code of Practice The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection issued 2004 contains the components that must be complied with by all NHS HCWs in Scotland. http://www.scotland.gov.uk/publications/2004/05/19315/36624 Clinical Standards Board for Scotland Sets standards for HAI, although the organisation is now called Quality Improvement Scotland. Standards set for infection control are still referred to as CSBS Standards. General Dental Practitioners Originally used to mean hospital acquired infection, the official Scottish Government term is now Healthcare Acquired Infection. These are considered to be infections that were not incubating prior to contact with a healthcare facility or undergoing a healthcare intervention. It must be noted that HAI infection is not always avoidable infection. Healthcare Worker Local agreed delivery plans set out by the Scottish Government and each NHS area Board. The key objectives are: Health - improvement of life expectancy Efficiency - and effectiveness of the NHS Access - quicker and easier use of NHS services for patients Treatment - appropriate to individuals Health Protection Scotland Infection Control Nurse Infection Control Team Infection Control Officer Infection Control Doctor 12

IHI IVOST LHBC MRSA MRSA bacteraemia programme NES PCAT PFPI PICC PIL SGHD SOP QIS Institute of Healthcare Improvement Intravenous to Oral Switch Therapy Local Health Board Co-ordinator for the National Hand Hygiene Campaign. Meticillin resistant Staphylococcus aureus A Staphylococcus aureus resistant to first line antibiotics; most commonly known as a hospital acquired organism. A mandatory surveillance programme requiring laboratories to inform Health Protection Scotland of all cases of MRSA bacteraemia. NHS Education Scotland Primary Care Audit Tool Patient Focus Public Involvement Partnerships Infection Control Committee Patient Information Leaflet Scottish Government Department of Health Standard Operating Procedure Quality Improvement Scotland See CSBS. 13