NHS Tayside Infection Prevention and Control Programme 2009/2010 Approval Record HAI Network Chief Executive Officer Medical Director Improvement and Quality Committee Risk Management/ Health and Safety Committee Date approved Signature NHST Infection Control Programme 2009/10
NHS Tayside Infection Prevention and Control Programme 2009/2010 Healthcare Associated Infection (HAI) is a priority patient safety issue at both a national and local level. It is embedded in the Scottish Patient Safety Programme and consistently highlighted as a major concern by the public. The Infection Control team have reviewed the 2008/09 programme, together with stakeholders including members of the public through the Public Partnership Group-HAI Forum to develop an Infection Prevention and Control Programme for 2009/10, which shares responsibility for minimising the risk of infection across NHS Tayside. For infection prevention and control to work effectively, critical activities such as hand hygiene and environmental cleanliness have to be embedded into everyday practice. All staff must transparently demonstrate good infection control and hygiene practice through leadership by example. Therefore, the Infection Control team will direct and support NHS Tayside in the control and prevention of infection, but local managers must take a lead role in implementing and monitoring interventions at ward and departmental level to provide an optimum environment and improve patient experience. This is highlighted within Leading Better Care (SGHD 2009) which articulates the Senior Charge Nurse (SCN) role in ensuring a clean and safe environment. This must be reflected not only by departmental heads but all staff. NHST Infection Prevention and Control Programme 2009/10 2
This programme has been guided by the Quality Improvement Standards (QIS) Self Assessment for HAI 2009, the existing Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection, the Government s 3 year Delivery plan for HAI and the recently reviewed cleaning standards. The NHS Tayside cleaning matrix will be reviewed to ensure it reflects the revised cleaning standards and a process that ensures each SCN / departmental head knows their local cleaning schedule will be implemented Progress against the actions is monitored by the HAI Network, which is chaired by NHS Tayside Chief Executive. A key priority in this year s programme will be to implement the zero tolerance approach to hand hygiene and improve compliance to 95% consistently across all staff groups. The latest audit report shows NHS Tayside with a compliance rate of 90%, which although significant progress, demonstrates further work is needed to ensure we demonstrate a consistent and reliable process. The Delivery Unit Executive Management Team support the recommended approach to zero tolerance and this will be implemented across all staff groups. The 2 nd stage of a local HAI Strategy will be implemented within the Community Health Partnerships and partner organisations to ensure a strategic response to HAI across NHS Tayside. This will be incorporated into Clinical Dashboards and will result in a clear picture of what the issues are and how collectively we can work to prevent and control infections across NHS Tayside. The pilot MRSA screening programme was tested in 3 Health Board areas and national rollout has been announced by the SGHD. NHS Tayside currently undertakes a large amount of routine screening anyway including critical care areas, nephrology, elective joint replacements, some of the NHST Infection Prevention and Control Programme 2009/10 3
surgical wards and some of the care of the elderly wards. Targeted screening operates in many other areas around risk factors (eg previous admissions etc. This will have significant implications for NHS Tayside and implementation will be achieved by working in partnership with managers, staff, patients and public across NHS Tayside. The Infection Prevention and Control Programme for 2009/10 reflects these priorities and also continues to focus on the high impact areas which are underpinned by the use of a balanced scorecard tool to assist monitoring and reporting on HAI all of which contribute to meeting the HEAT target for 2010 of reducing all Staphylococcus aureus bacteraemias by 35%, CDAD target and antimicrobial prescribing measures. Monitoring key areas using the balanced scorecard will be continued this year and extended to include areas of concern in the CHPs. The areas currently monitored via this tool and local targets are shown in appendix 1. The HAI agenda is wide-ranging and often complex. It impacts on both clinical and non-clinical areas and solutions require all services to plan and work together. Although preventing the spread of infection is about cleanliness, hand washing and environmental control, appropriate use of antibiotics, adherence to policies and ensuring staff working in all environments have access to the appropriate training and education all have a part to play. The Infection Prevention and Control Programme brings together all the main factors and looks at how the Infection Prevention and Control Team and partners must work together to ensure infection control is embedded in the practice of ALL staff in NHS Tayside. NHST Infection Prevention and Control Programme 2009/10 4
Specifically the programme for 2009/10 will aim to address the following: o Compliance with NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection (HAI Taskforce 2004, Scottish Executive). o Compliance with HAI Inspectorate Standards. o Compliance with CELs/CMO/CNO and other/scottish Health Technical Memoranda (SHTM) etc guidance documents. o Reduce MRSA acquisition rates. o Reduce Staphylococcus aureus bacteraemia rates by 30% to meet the HEAT target of March 2010. o Reduce the rate of new HAI Clostridium difficile infections in hospitals by at least 30% by 2011 to meet the HEAT target. o Reduce device associated infections in particular those associated with PIVC and central venous catheters o Enhance education/training in HAI ensuring increased number of Cleanliness Champions. o Improve hand hygiene compliance in accordance with the Scottish Government s expectations of a Zero Tolerance approach. o Surveillance of surgical site infections including post discharge NHST Infection Prevention and Control Programme 2009/10 5
o Reduce ventilator-associated pneumonias. o Reduce the number of needlestick injuries to staff o Ensure appropriate prescribing of antibiotics and compliance with antimicrobial prescribing measures o Improve decontamination of equipment, environment. o Improve communication of HAI matters. o Further develop the role and involvement of the Public Partnership Group o Maintain a safe environment with respect to Legionella assurance For further details on the Infection Control Programme please contact Dawn Weir, General Manager Infection Prevention and Control (dawn.weir@nhs.net or 01382 660111, ext 36627), or Dr Gabby Phillips, Lead Infection Control Doctor (gabby.phillips@nhs.net or 01382 660111 ext 33183). NHST Infection Prevention and Control Programme 2009/10 6
Objective Action Required Timescales Responsible person 1. GOVERNANCE Performance Indicator/ Outcome Progress Ensure NHS Tayside Board has clearly defined roles and responsibilities for Infection Control Define and develop a record of lead IC roles in each clinical and non clinical area and how these feed into the HAI Network reporting structure Dec 2009 GMs Agreed and document lead roles for each Directorate and CHP Agreed GMs are lead for secondary care and a lead has been identified for each CHP. Ensure national guidance is appropriately implemented Ensure infection control advice/guidance is accurate, consistent and adhered to across NHS Tayside Ensure local data is used to improve infection prevention and control Maintain current system for recording all national guidance and action taken Ensure policies are effectively communicated to managers and staff and monitor implementation plan in each area. Integrate balanced scorecard into clinical dashboards. GMs On-going. This system is now embedded into practice. GM IP&C/ Monitoring in GMs GM IP&C/ AND All staff aware how to access policies. All acute areas have access to Infection Prevention and Control data. progress via Audit programme. Weblink NHST Infection Control Programme 2009/10 8
Objective Action Required Timescales Responsible person Establish Infection Prevention and Control Directorate Consultation with all key stakeholders. Report to be taken to EMT and NHS Tayside Board for approval Performance Indicator/ Outcome Dec 2009 GM IP&C Directorate is established with clear lines of accountability and reporting. Progress October 2009 report out for consultation. NHST Infection Control Programme 2009/10 9
Objective Action Required Timescales Responsible person 2. PREVENTION AND CONTROL OF INFECTION HAI Strategy Develop stage 2 of an HAI strategy which defines the role of the community in the prevention and control of HAI and includes the role of the Care Commission and other partner organisations Ensure HAI is prioritised and addressed in clinical and nonclinical areas Integrate into clinical dashboards Work with JCB s and CHPs to develop infection control quality improvement plans HAI objectives to be included in Job Descriptions and PDPS. Review corporate HAI risks identified on SMART system April 2010 April 2010 Dec 2009 Dec 2009 GM IP&C, AND and GM CHP s GM IP&C/ GM s GM IP&C/ AND GM IP&C/ RM Performance Indicator/ Outcome Included KSF profiles. Reviewed 6 monthly. in job Progress NHST Infection Control Programme 2009/10 10
Objective Action Required Timescales Responsible person Hand Hygiene Improve hand hygiene practice and compliance through the development of a Zero Tolerance culture within the organisation Hand Hygiene (ctd) Increase HH awareness and technique among key groups of staff Undertake approximately 150 audits across SDU per annum Participate in national audits and feedback to EMT Feedback results to appropriate clinical manager and ensure improvement plans developed/ implemented. Provide relevant education and support for staff to enable them to provide effective feedback to their colleagues Monthly 2009/10 As determined nationally After each audit HHCOD/ Ken Armstrong ICNs ICNs/ HHCOD Performance Indicator/ Outcome Monitored through the monthly HH audit results Improvement and maintenance of high compliance rates Challenging of poor results and action taken to improve Monthly HHCOD Sample on a monthly basis the qualitative data from clinical areas audits Progress NHST Infection Control Programme 2009/10 11
Objective Action Required Timescales Responsible person Improve the awareness, understanding and technique within General Practice Assess HH compliance among Community Nursing staff Continue to make improvements across NHS Tayside in terms of the public s Hand Hygiene compliance Co-ordinate and implement the National Hand Hygiene Campaign Performance Indicator/ Outcome HHCOD HHCOD trains and supports Practice leads to deliver training sessions. Post training questionnaire will provide feedback April 2010 HHCOD/ Practice Managers HHCOD/ PPG Self audit tool developed NHS Tayside achieve 95% compliance. 2009/10 HHCOD Progress NHST Infection Control Programme 2009/10 12
Objective Action Required Timescales Responsible person Hand Hygiene (ctd) Antimicrobial Prescribing Ensure the HH improvement work is co-ordinated with the Scottish Patient Safety Programme (SPSP) Review and update all antimicrobial policies annually to reflect national guidance and new evidence. 2011 Diane Campbell April 2010 AMG/LDAP/L PAP Performance Indicator/ Outcome Implement a reporting mechanism which incorporates HH into the SPSP. Updated Tayside Area Prescribing Guide Progress 100% of HH audit results are being submitted within the SPSP spreadsheet. Spreadsheet being spread across NHS Tayside. Anticipated completion date of 2011 determined by speed of testing and implementation. NHST Infection Control Programme 2009/10 13
Objective Action Required Timescales Responsible person Implementation of empirical prescribing policy restricting antibiotics associated with C difficile infection Input data to HAI Balanced Scorecards for all areas Review and implement surgical prophylaxis policies Performance Indicator/ Outcome April 2010 LDAP/LPAP 95% compliance in admissions units (medical/surgic al/mfe) Monitor adverse outcomes e.g. nephrotoxicity LPAP Monthly data on quality of prescribing discussed for all areas. Onging AMG/LDAP/L PAP Agreed policies Updated TAPG 95% compliance with <24 hour prophylaxis Progress Implementation ongoing with education. Compliance measurements reported to clinical groups/hai Network/AMG/ Board General, Vascular, O&G, Urology currently under review. Ortho/Plastics/ENT/ Neurosurgery outstanding. Use SSI surveillance where possible to measure compliance. NHST Infection Control Programme 2009/10 14
Objective Action Required Timescales Responsible person Appropriate treatment for C difficile infections ICT/Pharmacy scheme Include antimicrobial prescribing in IC education talks Point Prevalance Study of antibiotic use on all wards in NW/PRI and Arbroath Implement policy for community hospitals Performance Indicator/ Outcome LPAP Monthly report on pharmacist interventions based on C difficile treatment guideline March 09 LPAP Increased education on importance of prescribing together with IC measures for all healthcare staff AMG Benchmark results with previous years and other sites in UK and Europe AMG/LDAP/L PAP PPS in all community hospitals from June-Dec 09 Progress Currently ongoing in NW medical, surgical and renal. To be spread to all areas and Angus hospitals, PRI Policy sent to CHPs for dissemination. Education to be arranged. NHST Infection Control Programme 2009/10 15
Objective Action Required Timescales Responsible person Develop Antibiotic Man for GPs and update TAPG to HPA format or similar Include antimicrobial prescribing in community pharmacist input to nursing homes through locally enhanced services (LES) Performance Indicator/ Outcome Dec 09 LPAP <5% seasonal variance in quinolone prescribing in GP practices Aug 09 LPAP Improved knowledge of antimicrobials for community pharmacists and nursing home staff Progress Medicines unit have included indicator (and cephalosporin use) in quarterly GP report. Initial meeting with LES steering group arranged for April 09 NHST Infection Control Programme 2009/10 16
Objective Action Required Timescales Responsible person Reduction of needlestick and sharps injuries Reduce Staphylococcus aureus bacteraemias by 35% by 2010 Reduce intravascular device associated infections Undertake needlestick devices scoping study and implement recommendations. Ensure effective ongoing SAB surveillance occurs including feedback of data to clinical staff for improvement purposes. Monitored via Taystat and scorecard Implement ICNs prescribing Mupirocin as part of decolonisation process Full implementation and compliance with PVC bundle Continue CVC surveillance in the renal and surgical unit and roll out to other areas to include community Dec 2009 AND/ H SG+R Performance Indicator/ Outcome Monitor compliance 2010 HEAT Target achieved Dec 2009 GM IP&C/ AND/ ICNs Dec 2009 SG&R / AND 95% compliance 2010 Unit specific All CVCs part of surveillance programme and 95% compliance achieved. Progress NHST Infection Control Programme 2009/10 17
Reduce the incidence of Ventilator Associated Pneumonia (VAP) Undertake SSI surveillance including post discharge Review and standardisation of Alert conditions surveillance VAP surveillance system Monitor via scorecard 2010 GMs 2009/10 SNIC CSMs Critical Care Objective Action Required Timescales Responsible person New MRSA acquisitions Surveillance in target areas On going ICA 95% compliance Performance Indicator/ Outcome Monitor via scorecard Progress Full introduction of national MRSA screening programme 2009/10 GM IP&C Audit MRSA decolonisation scripts as prescribed by ICNs (10 samples per annum) Annually SNIC In line with policy 100% NHST Infection Control Programme 2009/10 18
Implement CJD/vCJD assessment New consent forms to be implemented October 2009 GM IP&C/ SG&R Consent form out for consultation 3. EDUCATION Review Education and Training Strategy Implement training on infection control precautions in the event of an outbreak of pandemic influenza Dec 2009 AND / SNsIC Strategy launched. Oct 2009 ICD/HPT All areas will achieve the target of 4 cleanliness champions. Implement knowledge and skills framework for IC Nursing and Administration staff March 2010 SNsIC/ Local Managers Target achieved Dec 2009 AND 100% IC staff have knowledge and skills framework for their post In progress. NHST Infection Control Programme 2009/10 19
Objective Action Required Timescales Responsible person 4. ENVIRONMENT AND EQUIPMENT Performance Indicator/ Outcome Progress Environmental audits Ensure optimum environment to minimise risk of infection Introduce an electronic environmental SDU tool Ensure monitoring via scorecards December 2009 SNsIC March 2010 SNsIC/HE More efficient use of ICN time and reduce paperwork Delayed due to technical issues. Audit compliance with the Estates infection control policy and use of SCRIBE SCNs to complete environmental audits Audit a minimum of 25% of General Medical Practices Jan 2010 HE 100% compliance March 2010 GM IP&C/ AND ICNs First cohort of RTC SCNs using audit tool Target achieved NHST Infection Control Programme 2009/10 20
Cleaning Cleaning (ctd) Develop business case for introduction of housekeeper roles Monitor national cleaning data. Board report scorecard Review/extend wheelchair, trolley and bed washing system 2010 DSMs/OPS Housekeepers implemented On going GM IP&C/ SNsIC All hospital premises over 90% compliant 2010 OPs Cleaning system agreed and implemented Minimise risk of infection from this equipment National data reported in bimonthly Board report. NHST Infection Control Programme 2009/10 21
Objective Action Required Timescales Responsible person Cleaning (ctd) Decontamination Develop a decontamination strategy for NHST which ensures compliance with national guidance Implement revised cleaning matrix Develop Business Case and action plan for primary care compliance Develop a Business Case for compliant decontamination of ENT scopes Performance Indicator/ Outcome Dec 2009 AND/DSM Minimise risk of infection from environment/ equipment Dec 09 HOP Approval by SP&R Committee and HPS Glennie compliant Progress Dec 2009 EDM Work ongoing for Initial Agreement approval by SP&R Committee And HPS Compliant decontamination of Nasendoscopes. NHST Infection Control Programme 2009/10 22
Seek Infection Control Advice before purchase of medical/ other equipment March 2010 GM IP&C/ Head of Procurement Adherence process. to Process Implemented to ensure IC advice is sought prior to purchase of medical/ other equipment. Audit of 20 requisition forms per year to cross check that IC advice has been sought during procurement and this cross checks with IC records July 2010 Procurement/ ICT 100% cross reference of IC advice on the equipment purchase NHST Infection Control Programme 2009/10 23
Objective Action Required Timescales Responsible person 5. PATIENT FOCUS & PUBLIC INVOLVEMENT Develop systems which encourage patients to challenge the standards of infection control and to improve the public understanding of infection prevention and control Communication Improve all stakeholder and public understanding of infection prevention and control Continue with the PPG HAI Forum Consult with PPG HAI Forum on annual programme and subsequent monitoring of progress Review of all IC leaflets and action plan to address gaps in information Performance Indicator/ Outcome Bi-monthly GM IP&C Membership of PPG HAI Forum Agreed Terms of Reference. June 2009 GM IP&C Greater public then ongoing ownership of HAI agenda in NHS Tayside November 2009 GM IP&C / SNsICs Ensure HAI information is accurate and comprehensive Progress Complete/Ongoin g 30% completed NHST Infection Control Programme 2009/10 24
6. PPG HAI WORK PROGRAMME 2009/10 Ensure HAI information is provided in terms easily understood by the general public As a group advise on the content and presentation of all leaflets On going GM IP&C/ PPG HAI User friendly information System in Place NHST Infection Control Programme 2009/10 25
Objective Action Required Timescales Responsible person PPG HAI Work Programme (ctd) To promote hand hygiene in healthcare settings and improve and sustain public awareness of Hand Hygiene Participate in hospital walk abouts to assess hand hygiene facilities Continue to involve the PPG members in developing appropriate information and awareness raising events On going HHCOD/Vs Performance Indicator/ Outcome Progress On going programme On going Input into the hospital environment monitoring systems to ensure it is kept at an optimum state of cleanliness Participate in National Cleaning Specification Audits Participate in environmental audits and review action On going DSMs/Vs Improved monitoring Greater public accountability On going GM IP&C/ HE/ICNs/Vs Improved monitoring Greater public accountability On going Closed loop system with 14 day turnaround for red audit actions 21 days for amber agreed NHST Infection Control Programme 2009/10 26
Appendix 1 - INFECTION CONTROL TEAM ORGANISATIONAL CHART Chief Operating Officer SDU Associate Director of Nursing (Access) SDU Associate Medical Director SDU Nurse Consultant (Healthcare Associated Infection) Lead Infection Control Doctor/ General Manager Infection Prevention & Control Infection Control Doctor Infection Control Advisor (Perth & Kinross, Angus) Hand Hygiene Co-ordinator Infection Control Advisor (Dundee) Endoscopy Decontamination Manager Infection Control Nursing Team (Perth & Kinross, Angus) Infection Control Statistician Infection Control Nursing Team (Dundee) Cleanliness Champions Co-ordinator Supported by a team of secretarial and administration staff ADN (Access) will provide professional leadership to the ICNs. NHST Infection Control Programme 2009/10 27
Glossary Abbreviation COG CVCN DHR DSMs GM IPC HC HE HEAT HEAT 1 HHCOD HLL HPT HS ICD ICT JCB LG LICD LPAP NC HAI OPs PPG SCN Meaning Communications Group Central Venous Catheter Nurse Director of Human Resources Domestic Service Managers General Manager Infection Prevention and Control Head of Communication Head of Estates Health improvement, Efficiency and governance, Access to services, and Treatment Target for 2010 of reducing all Staphylococcus aureus bacteraemias by 35%. Hand Hygiene Co-ordinator Head of Lifelong Learning Health Protection Team Head of Supplies Infection Control Doctor Infection Control Team Joint Clinical Boards Legionella Group Lead Infection Control Doctor Lead Pharmacist Anti-microbial Prescribing Nurse Consultant (Healthcare Associated Infection) Director of Operations Public Partnership Group Senior Charge Nurse NHST Infection Control Programme 2009/10 28
SNsIC SPI SR & G Senior Nurses Infection Control Safer Patient Initiative Safety Risk & Governance NHST Infection Control Programme 2009/10 29
INFORMATION for DIRECTORATES and CHPS INFECTION PREVENTION AND CONTROL STRATEGY 2009/10 http://staffnet.tayside.scot.nhs.uk/nhstaysidedocs/idcplg?idcservice=g ET_FILE&dDocName=DOCS_020302&Rendition=web&RevisionSelectio nmethod=latestreleased&nosaveas=1 ZERO TOLERANCE TO NON COMPLIANCE IN HAND HYGIENE 1. NHS Tayside Approach CEL 5 (2009) Zero Tolerance to Non Hand Hygiene Compliance http://staffnet.tayside.scot.nhs.uk/safeeffectiveworking/infectionprevention andcontrol/handhygiene/sslink/docs_039405 2. CEL 5 (2009) Zero Tolerance to Non Hand Hygiene Compliance http://www.show.scot.nhs.uk/publications/cel_5_2009_zero_tolerance_t o_non_hand_hygiene_compliance_january_2009.pdf NHST Infection Control Programme 2009/10 30