Control of Infection Committee: Overarching Work Programme 2015 16 To be updated as required, at least on a quarterly basis. Action Responsibility Timescale / progress 1 1.1 SURVEILLANCE Healthcare Associated Infection MRSA (local surveillance) SAB Enhanced Surveillance Clostridium difficile Infection local & national surveillance Surgical Site Infection Surveillance (SSIS) Patient safety programme Scottish HAI Outbreak Online Reporting System SHORS Resistant organisms surveillance Weekly Norovirus and Influenza Outbreak monitoring Overall Responsibility: Director of Public Health (ST) Public Health ( SL) Public Health (SL) Public Health (SL) Public Health (KG / WH) Clinical Governance Team Public Health (SL / ST) Laboratory / Public Health (TW / SL) Public Health (KG) (Quarterly reports) 1.3 Communicable disease surveillance (including immunisation uptake) 1.4 Sharps injuries (Including investigation of increase in sharps injuries in any clinical area) Public Health (KG / SL / Andy Hayes) Occupational Health (BD) (Quarterly reports) (Quarterly reports) 1
2 2.1 TRAINING (part of and in line with Board Training Plan) All staff have HAI CPD objectives included within PDPs Overall Responsibility: Infection Control Manager (CB) Line Managers 2.2 Awareness raising and publicity for infection control training and useful resources through Staff Development Bulletin 2.3 Incorporation of infection control into all training run by Staff Development where appropriate Staff Development / Infection Control Nurse (TB-I) Staff Development (Sally Hall) / Infection Control Nurse (TB-I) Quarterly updates for bulletins 2.4 Clinical skills training (relevant infection control elements) Staff Development 2.5 Reviewing and updating of Induction and mandatory refresher training materials as required Infection Control Nurse (TB-I) Induction and compulsory refresher training 2.6 Implement Learnpro HAI Clinical & Non-clinical Induction modules (to replace Corporate Induction face to face session) Staff Development (Sally Hall) / Infection Control Nurse (TB-I) By end June 2015 2.7 Compulsory refresher (face to face) Infection Control Rota of ICT members (monthly) 2.8 LearnPro for all staff - waste procedures; Staff Development (Andrew Humphrey) / Infection Control Nurse (TB-I) 2.9 LearnPro: implement compulsory modules for all clinical staff NES aseptic technique; NES Clostridium Difficile on-line tutorial; NES MRSA on-line tutorial; Food Handling Staff Development (Andrew Humphrey) / Infection Control Nurse (TB-I) Implemented as compulsory by end September 2015 2
2.10 FFP3 Fit testing ( process in place to train fitters; fit existing staff; and new staff as part of induction) H&S Manager (Jean Diggle) / Chief Nurse - Acute (JM) / Infection Control Nurse (TB-I) / Dept Fitters 2.11 Staff Nurse Induction Training Infection Control Nurse (TB-I) 2.12 Healthcare Support Worker induction training Infection Control Nurse (TB-I) 2.13 Infection control training for doctors - through SHO / Medical Student and Postgraduate Education Programmes. Including learnpro modules on CDI and MRSA. Infection Control Nurse (TB-I) / Public Health (ST) / Post Graduate Administrator (Lisa Turner) (quarterly) 2.14 Hand hygiene for contractors Infection Control Nurse (TB-I) As required 2.15 Clinical waste training for Waste Customers Infection Control Nurse (TB-I) As required 2.16 CDU staff training CDU Manager (CB) 2.17 Hand hygiene educational sessions (including skin care) for teams / departments Infection Control Nurse (TB-I) on request 2.18 Contamination Incident/ Needle Stick Injury Training Senior Occupational Health Advisor (BD) On request 2.19 Cleanliness Champions training (NES on-line package) Staff Development (Mhari Roberts) / Infection Control Nurse (TB-I) / Chief Nurse Community Health and Social Care (EMW) 2.20 Other LearnPro / NES HAI modules Staff Development (publicity through Staff Development Bulletin see 2.2) / Individual staff (PDPs) 2.21 Infection Control Team: individual PDPs and training programmes KC / ST / CB / TB-I/ SL / WH / EMW / JM / BD /CD /LB 3
Immunisation training 2.22 HPS/NES Immunisation on-line training (Promoting Effective Immunisation Practice) Immunisation Co-ordinator (SL) / Immunisers 2.23 Local annual Immunisation update training Immunisation Co-ordinator (SL) 2 sessions by end July 2015 2.24 CRBN Decontamination CRBN decontamination training A&E staff (Aimee Sutherland) / Estates / Emergency Planning and Resilience Officer (Ingrid Gall) May / June 2015 2.25 HAI SCRIBE Training by HFS for all relevant staff (see 8.2) HFS / Head of Estates (LB) / infection Control Manager 11 th June 2015 3 POLICY & PROCEDURE DEVELOPMENT : Infection control in healthcare setting Overall Responsibility: Infection Control Manager 3.1 Ensure all new policies marked with review date Authors of each individual policy 3.2 Ensure assessment of all policies against Equality and Diversity Impact Assessment Toolkit 3.3 Continue to update infection control procedures against national guidance ( chapters 3 &4) Authors of each individual policy Infection Control Nurse (TB-I) as required Infection Control Procedures due for review 3.4 SOP - Planned Curtain Changes Infection Control Nurse (TB-I) February 2016 3.5 SOP Unitron Keyboards Infection Control Nurse (TB-I) CF - was due Feb 2015 4
3.6 Policy for Staff Screening during HAI incidents / outbreak Occupational Health (BD) December 2015 3.7 Procedure for the Prevention of Occupational Infection with BBVs Occupational Health (BD) October 2015 Public Health plans etc new / due for review 3.8 Guidelines for prevention of sepsis in patients with splenic dysfunction (to complete) Overall Responsibility: Director of Public Health (ST) Public Health (SL) CF June 2015 3.9 Pandemic Flu Plan Public Health (SL) CF July 2015 3.10 PH Incident / Outbreak Plan (Overarching generic plan) Public Health (SL) End October 2015 3.11 Legionella Plans - consolidate Environmental Health & Public Health (TBA) CF July 2015 3.12 Blue Green Algae Plan Environmental Health & Public Health (TBA) CF July 2015 4 4.1 PREVENTION OF HAI: DECONTAMINATION CDU: re-certification to ISO 13485:2003 and the Medical Device Directive Overall Responsibility: Infection Control Manager Decontamination Lead / ICM (CB) July 2015 5. PREVENTION OF HAI: INFECTION CONTROL Overall Responsibility: Infection Control Manager 5.1 Continued Implementation of Hand Hygiene programme Infection Control Nurse (TB-I) 5.2 Continue Cleanliness Champions programme Infection Control Nurse (TB-I)/ Staff Development (Mhairi Roberts) / Chief Nurse Community Health and Social Care (EMW) 5.3 Action to achieve HEAT target: to reduce SA bacteraemias (including surveillance; implementation of procedures; patient safety bundles) All members of Infection Control Team / Senior Charge Nurses 5
5.4 Ensure that training and learning outcomes in relation to HAI are standardised and included in: Mandatory training Corporate induction Clinical area level induction New start checklists for HCSWs Waste management training for all clinical staff Root cause analysis as part of HAI outbreak investigations and all SAB / C. Difficle cases Decontamination lead / (CB) / Infection Control Nurse (TB-I) 6 PREVENTION OF HAI: GOVERNANCE & REPORTING 6.1 HAI incident and near miss reporting; raise awareness and implement risk matrix. Infection control risks and incidents to be reported to CoIC quarterly Infection Control Team / Public Health (KG) Quarterly reporting 6.2 Organisational lead from CE through SMT on expectations, priority of HAI, follow-up of poor performance demonstrated through team briefs; safety conversations; management of poor performance and zero tolerance 6.3 Performance management of individuals by managers including objective setting 6.4 Regular walk-arounds (Patient Safety conversations) undertaken by senior managers Chief Executive (Ralph Roberts) All Senior Managers Senior Managers / Chief Nurse - Acute (JM) / Head of Estates (LB)? 6
6.5 Develop a process for collating and reporting positive and negative feedback on infection control issues from a variety of sources including formal / informal complaints; Patient Opinion; comments & suggestions; media coverage etc. And triangulate with data from incident; audit and inspection reports. Infection Control Manager (CB) / Public Health (SL) / Corporate Services Manager (Carolyn Hand) By end December 2015 Reporting: 6.5 2 monthly Board reports Infection Control Manager (CB) 6.6 Produce CoIC Annual Report 2014-15 and present to Clinical Governance Committee CoIC (ST ) July 2015 7 PREVENTION OF HAI: PATIENT SAFETY 7.1 Take forward the patient safety programme methodology as set out in the iiip Infection Control Manager (CB) / Infection Control Nurse (TB-I) 8 PREVENTION OF HAI: ESTATES AND FACILITIES Overall Responsibility: Infection Control Manager 8.1 Monitoring of Hospital Cleaning Standards Hotel Services Manager (VL)/ Infection Control Nurse (TB-I) / Interim Head of Estates (LB) (Quarterly reporting to CoIC) Implementation of new SCRIBE process Overall Responsibility: Infection Control Manager / Head of Estates 8.2 Training by HFS for all relevant staff (see 2.27) HFS / Head of Estates (LB) 11 th June 2015 8.3 Implementation of documentation for all refurbishment and building works Infection Control Manager (CB) / Head of Estates(LB) June 2015 and ongoing 7
8.4 Hospital Capital Plan Ensure infection control issues addressed within plans for building works including: Design of clinical areas New fixtures, fittings & equipment Appropriate infection control measures during building works Reports to CoIC Repeat HAI SCRIBES after works completed Overall Responsibility: Head of Estates 8.5 Specific capital projects: TBA Interim Head of Estates (LB) 9 PREVENTION OF HAI: Antimicrobial prescribing Continued implementation of Antimicrobial Prescribing Action Plan Overall responsibility: Medical Director 10 PREVENTION OF HAI: Implementation of HAI Standards 2015 Overall responsibility: Director of Nursing and Acute Services 10.1 Self assessment against standards Infection Control Manager (CB) June 2015 10.2 Actions identified from self assessment TBA TBA 10.3 Actions identified following unannounced inspection TBA TBA 8
11 PREVENTION OF HAI: VALE of LEVEN ACTION PLAN Overall responsibility: Director of Nursing and Acute Services CoIC Work Programme 2015-16 11.1 Consider including infection control management as a specific factor in our existing project management methodology Director of Nursing and Acute Services (KC) June 2015 11.2 Learnpro / NES C diff Online tutorial to be compulsory for clinical staff (see 2.9) Staff Development (Andrew Humphrey) / Infection Control Nurse (TB-I) June 2015 11.3 Implement audit of completed Infection Control Care plans for patients with CDI and report to ICT 11.4 Implement audit of compliance to and understanding of the use of the Bristol Stool Chart on a monthly basis 11.5 Formalise the link nurse role for tissue viability in nursing job descriptions 11.6 Build into the existing audit programme, criteria to assess compliance with the wound care management process. 11.7 Build into the existing audit programme, criteria to assess compliance with the comfort rounding process. Infection Control Nurse (TB-I) April 2015 Infection Control Nurse (TB-I) May 2015 Chief Nurse - Acute (JM) June 2015 Chief Nurse - Acute (JM) / Infection Control Nurse (TB-I) May 2015 Chief Nurse Acute (JM) / Infection Control Nurse (TB-I) May 2015 11.8 review of medical staffing levels as part of planned workforce work Director of Nursing and Acute Services (KC) / Medical Director (Roger Diggle) By end March 2016 11.9 Investigation policy - detail when external advice should be sought as part of an internal investigation process. Director of Nursing and Acute Services (KC) June 2015 9
12 OUTBREAK PREPARATION AND MANAGEMENT Overall responsibility: Director of Public Health CoIC Work Programme 2015-16 12.1 Participation in National Pandemic Flu planning exercises (Exercise Silver Swan) Public Health (ST/SL) May November 2015 13 AUDIT PROJECTS (SEE AUDIT PLAN AT END) Overall Responsibility: Infection Control Manager 13.1 Monthly Cleaning Hotel Services Manager (VL), Lay member Monthly ongoing 13.2 MRSA Screening KPIs quarterly audit ICN (TB-I) Quarterly 13.3 CPE Screening quarterly audit ICN (TB-I) Quarterly 13.4 HAI Environmental Audit programme ICN (TB-I) Frequency as req 13.5 Hand hygiene Link Nurses Quarterly 13.6 Leaflet audit Link Nurses Quarterly 13.7 Infection Control Manual Audit Link Nurses Quarterly 13.8 Bristol Stool Chart Link Nurses monthly 13.9 Catheter Assoc Urinary Tract Infection Audit ICN (TB-I) Monthly 13.10 Green Tape Audit Link Nurses Quarterly 13.11 Fridge Audit Link Nurses Six monthly 13.12 Mattress Audit Link Nurses Annually 13.13 All other Standard Infection Control Precaution Audits Link Nurses Six monthly 13.14 Audits in response to Vale of Leven Report (see above) ICN (TB-I) Varies 10
14 PATIENT FOCUS PUBLIC INVOLVEMENT Overall Responsibility: Infection Control Manager 14.1 Increase public involvement in policy & procedures development and review Infection Control Nurse (TB-I) / Cleanliness Champions 14.2 Continue to develop & disseminate HAI information to the public, patients, families & carers Infection Control Nurse (TB-I) / Cleanliness Champions 14.3 Increase public involvement in cleaning & hand hygiene monitoring Infection Control Nurse (TB-I) / Cleanliness Champions 14.4 Public involvement with Environmental Audits and other infection control issues Chief Nurse - Community Health and Social Care (EMW) 14.5 Development of a Patient Feedback Form specifically focused on HAI Infection Control Nurse (TB-I) / Camille Brizell (SHC) July 2015 14.6 Introduction of leaflet for patients with suspected food poisoning etc. in Primary Care Public Health (SL) / Environmental Health (Dawn Manson) July 2015 11
KEY: CB Carol Barclay* Decontamination Lead / Infection Control Manager LB Lawson Bisset* Head of Estates TB-I Tina Bokor Ingram* Infection Control Nurse KC Kathleen Carolan* Director of Nursing and Acute Services CD Carol Dade Senior Dental Nurse Infection Control BD Bernadette Dunne* Senior Occupational Health Advisor PD Patti Dinsdale* Team Leader - Environmental Health (SIC) KG Kim Govier Public Health Secretary WH Wendy Hatrick* Public Health Nurse Specialist VL Val Lafferty* Hotel Services Manager SL Susan Laidlaw* Consultant in Public Health Medicine JM Janice McMahon* Chief Nurse - Acute ST Sarah Taylor* Director of Public Health EMW Edna Mary Watson* Chief Nurse Community Health and Social Care TW Trevor Wilson Biomedical Scientist Microbiology (GBH Lab) *member of Control of Infection Committee 12