NOT PROTECTIVELY MARKED Public Board Meeting January 2018 Item No 11 THIS PAPER IS FOR DISCUSSION PATIENT AND STAFF SAFETY HEALTHCARE ASSOCIATED INFECTION (HAI) UPDATE REPORT Lead Director Author Action required Key points Pat O Connor, Director of Care Quality and Strategic Development Vincent McCluskey, Lead Infection Control Advisor The Board is asked to note/discuss this update report. The Service continues to sustain the required level of compliance against mandatory audits for hand hygiene and cleanliness of the healthcare environment. Good compliance with Standard Infection Control Precautions is also being maintained. The new 5 moments for hand hygiene posters have been distributed across the Service and a national bulletin was distributed informing staff of the mandatory requirement to complete the new NHS Education Scotland hand hygiene module (Pages 3, 5 10). Please note the missing data points on some of the run charts on pages 5-10 was due to a lack of resource to complete audits as the department was undergoing a period of recruitment. Timing Link to Corporate Objectives Contribution to the 2020 vision for Health and Social Care Benefit to Patients Good progress continues against the new target for recording application of the PVC insertion bundle (Page 4) This paper is presented to the Board bi-monthly in the Scottish Government s prescribed template. 2.1 - A patient safety work programme must include ongoing work to prevent and reduce the risk of HAI for patients, staff and the public. The work and information referred to in this report supports the Service in its contribution to the 2020 Vision for Health and Social Care in relation to Safe and Effective Care. Safe clinical practices, a clean environment and patient care equipment protect patients from the risk of Healthcare Associated Infection (HAI). Doc: 2018-01-31 HAI Update Page 1 Author: Infection Control Advisor
Equality and Diversity Healthcare Associated Infection (HAI) policies apply to all staff and patient groups. These are based on NHS Scotland HAI policy and Guidance. Health Protection Scotland (HPS) and Healthcare Improvement Scotland (HIS) conduct equality impact assessment on all HAI national guidance, policy and standards. The hand hygiene, Standard Infection Control Precautions (SICPs) and cleanliness audit results reported are a mandatory HAI requirement related to national policy and guidance. Doc: 2018-01-31 HAI Update Page 2 Author: Infection Control Advisor
Healthcare Associated Infection Report January 2018 Standard Infection Control Precautions (SICPs) Audit: Service overall compliance with Standard Infection Control Precautions (SICPs) is being sustained at a high level, achieving between 96- over the past 9 months. SICPs compliance is reported to Regional management for cascade to station/staff level for improvement action. SICPs compliance is also reported monthly on the news section of @SAS. Hand Hygiene Scottish Ambulance Service overall hand hygiene compliance has remained in the range of 90- in the last few months. Further attention is required in all areas to continue to improve on this. Compliance in West Central remains variable with improvement to in September but this was not sustained in October or November although there has been a slight improvement to 89% in December. An action plan has been developed by management to address this. Hand hygiene results are communicated to each divisional area as an element of the SICPs reports for improvement action. The new 5 moments for hand hygiene posters and pocket cards have been distributed across the Service to help raise awareness. Numbers are currently being collated to arrange distribution of the pocket cards to the community first responder groups. A national bulletin was distributed informing staff of the mandatory requirement to complete the new NHS Education Scotland hand hygiene module available on Learnpro. Hand hygiene compliance scores for the Service overall and each Division for the last year are reported in section 2. Infection Control Environmental (Rivo) Audit: Regular infection control environmental audits are conducted across the Service. During November and December the majority of 52 vehicle audits conducted (52%) achieved above. Results and non-compliances by individual station are reported to Regional area Management. Station Managers are responsible for addressing rectifications for improvement and cascading audit results to staff. Cleaning and the Healthcare Environment Service overall compliance against NHS Scotland s National Cleaning Services Specification (NCSS) continues to meet the required standard for both cleanliness and general fabric (Estates) of stations and ambulances. NCSS monthly compliance results for both cleaning and estates, for Scottish Ambulance Service overall and each Division in the last year are reported in section 2. Doc: 2018-01-31 HAI Update Page 3 Author: Infection Control Advisor
Outbreaks/Incidents: Weekly data on NHS Scotland Hospital ward closures due to Norovirus is circulated to the Ambulance Control Centres (ACCs) for information. Towards the end of December 2017 there was an increase in cases of seasonal flu across Scotland which was having a moderate impact on the population. HAI Training/Development: Scottish Infection Prevention and Control Education Pathway (SIPCEP): A national bulletin was distributed to inform and guide staff on how to access NHS Education Scotland s new infection prevention and control education pathway on Learnpro. The hand hygiene module is mandatory for this year. Peripheral Venous Catheter (PVC) Insertion Bundle: Good progress continues to be made on compliance with recording application of the PVC insertion bundle which was 88.6 % in November and 92.4% in December against a target of 85%. Vincent McCluskey Lead Infection Control Advisor 12/01/2018 Doc: 2018-01-31 HAI Update Page 4 Author: Infection Control Advisor
Section 2 Hand Hygiene and National Cleanliness Standards Compliance The following series of Run Charts provide information, for the Scottish Ambulance Service overall and each Operational area of the Service on hand hygiene and cleaning compliance for the period January 2017 December 2017 SCOTTISH AMBULANCE SERVICE OVERALL REPORT CARD Hand Hygiene Compliance Overall 89% 89% 89% SAS Cleaning Compliance Overall Estates Compliance Service Overall Doc: 2018-01-31 HAI Update Page 5 Author: Infection Control Advisor
EAST REGION - SOUTH EAST REPORT CARD Hand Hygiene Compliance South East Division Cleaning Compliance South East Division Estates Compliance South East 89% Targert Doc: 2018-01-31 HAI Update Page 6 Author: Infection Control Advisor
EAST REGION - EAST CENTRAL REPORT CARD Hand Hygiene Compliance East Central Division 89% Cleaning Compliance East Central 85% Estates Compliance East Central Division Targert Doc: 2018-01-31 HAI Update Page 7 Author: Infection Control Advisor
WEST REGION - WEST CENTRAL REPORT CARD Hand Hygiene Compliance West Central 87% 83% 81% 89% Cleaning Compliance West Central Division 99% Estates Compliance West Central Division 99% Targert Doc: 2018-01-31 HAI Update Page 8 Author: Infection Control Advisor
WEST REGION - SOUTH WEST REPORT CARD Hand Hygiene Compliance South West Division Cleaning Compliance South West Division Estates Compliance South West Division Targert Doc: 2018-01-31 HAI Update Page 9 Author: Infection Control Advisor
NORTH REGION REPORT CARD Hand Hygiene Compliance North Division Cleaning Compliance North Division Estates Compliance North Division 99% Targert Doc: 2018-01-31 HAI Update Page 10 Author: Infection Control Advisor