INFECTION PREVENTION CONTROL (IPC) DELIVERY PLAN 2010 IPC Corporate : - To achieve the irreducible minimum in Healthcare Associated Infection in the Northern Trust Local (Principal) 1.0 Accountability for Healthcare associated infection (HCAI) is clearly defined and understood at all levels in the Trust. RQIA IR 1 IR 2 IR 3 FR 10 Current Position Future State Actions Required Timescale Accountable Strong visible leadership with respect to prevention of HCAI. NHSCT Infection Prevention and Control Accountability Structure approved. are developing and implementing directorate specific HCAI Accountability Frameworks. lead HCAI prevention within individual directorates and report to Trust Board on key performance indicators. A multi-disciplinary HCAI review panel holds individual officers to account for new cases of HCAI. ership walkabouts in all trust facilities focus on HCAI prevention and environmental cleanliness. complete and operationalise directorate specific Accountability Framework for all staff. will map out and communicate to officers at each level the processes to be used for holding to account for HCAI performance. Sustained reduction in HCAI s as evidenced by internal reporting mechanisms, external reviews and trust performance monitored against PfA targets. HCAI standing agenda item at monthly directorate governance meetings. Directorate HCAI report tabled at GMB. DIPC / Meetings notes and actions emanating from same. Reporting frequency agreed on a range of key performance indicators including: Cdifficile, MRSA and MSSA bacteraemias, Hand Hygiene, HII s, Environmental cleanliness Antibiotic prescribing A dashboard of KPIs (both outcomes and processes) developed and implemented. Introduce KPIs for HCAI into management supervision processes at all levels. Datasets reviewed in directorate governance meetings and by GMB and IPCEHC. Action plans developed and targeted DIPC / Reports and action plans developed as result of same. 1
1.0 continued Current Position Future State Actions Required Timescale Accountable support for areas of high risk / low confidence introduced. Dashboard for each clinical area displayed on IPC notice board for staff, patients, relatives and carers to review. Staff fully engaged in HCAI prevention. Evidence based policy and procedure integrated into clinical practice, 100% compliance with same. Experiences of individual 30 November service users captured and shared with staff to reinforce importance of 100% compliance with delivery of evidence based practice and impact of diagnosis of HCAI for the person / relatives / carers. Visible datasets in all clinical areas. Monitored by IPC nurses. HII data and action plans developed and reports from IPC nurses where compliance drops and targeted support required. Nominated Directorate for HCAI s appointed within operational directorates. NDL report on dashboard of KPI s at directorate governance meetings and IPCEHC. NDL monitors action plans for areas of high risk / low confidence and trends from RCA s. Directorate governance meetings reflect priority of HCAI and develop partnership working with IPC nurses to embed evidence based practice and 100% compliance with same. 31 October / DON / NDL NDL reports, directorate governance meeting notes, IPC audit reports, external reviews. 2
1.0 continued Current Position Future State Actions Required Timescale Accountable NHSCT Strategy for IPC to be developed. NHSCT Strategy for IPC to be developed and launched. Facilitation of strategy development to be led by Organisational Development Team. 30 November DIPC / DON Strategy launch. Annual programme for HCAI developed from strategy document and presented to GMB and Trust Board for approval. Evidence base for clinical practice evaluated against research. Trust performance benchmarked against comparable organisations. Excellence in practice celebrated. Focused IPC nursing team development to be facilitated by DoH Cleaner Hospitals Team to inform prioritisation of work streams for 09 / 10 DIPC / DON Programme of activity endorsed by IPCEHC. Policy reviews completed. Trust audit data compared with comparable organisations regionally and nationally. 3
2.0 Staff at all levels are aware that the Trust has a Zero Tolerance approach to HCAI. RQIA IR 18 RQIA FR 9 / FR 15 Current Position Future State Actions Required Timescale Accountable CEO has communicated to all Clear expectation for Continued reinforcement CEO staff that HCAI bacteraemia / compliance with policy and of zero tolerance infections are avoidable and procedures reinforced to all message. that the Trust is adopting a staff. Monitoring systems 31 October zero tolerance approach to established to same. demonstrate 100% compliance with trust policies and procedures. Demonstrable delivery of sustained improvement on reducing HCAI s. (Performance data, external reviews) Trust achieves agreed trajectory on MRSA / MSSA bacteraemia reduction and C. Difficile infections. Addendum to all staff contracts. Accountability and responsibility for HCAI embraced at all levels of the organisation. Infection control is everybody s business is reflected as a core value within the organisation. A multi-disciplinary HCAI review panel holds individual officers to account for new cases of HCAI. IPC nurses highly visible in clinical areas to reinforce best practice and challenge noncompliance. Infection prevention and control notice boards display performance and compliance data for staff patients and visitors. 31 July DON 4
Current Position Future State Actions Required Timescale Accountable 2.0 continued All staff made aware of their contractual and employment obligations to comply with Trust Policy and Procedures with respect to HCAI. Disciplinary procedures initiated where evidence based policy and procedure not consistently reflected in clinical practice. RCA trends, HII data, hand hygiene audits and environmental cleanliness scores reviewed and immediate action taken if compliance drops below agreed parameters. Compliance with policy and procedure demonstrated. Incident reporting forms completed if policy is breached generating directorate based investigation and action. Documented audit trail of actions taken when noncompliance with same. Learning culture fostered with development and ownership of directorate based actions with respect to HCAI prevention. 5
3.0 Staff within the Trust can access evidence based policy and procedure and demonstrate compliance. RQIA FR 8 FR 15 Link to Regional IPC Policy Harmonisation of regional Working Group to DIPC Manual on Trust Intranet. and local policies reflecting undertake policy review Working group established to relevant legislation and programme. harmonise regional and local evidence based practice policies to ensure consistent completed. IPC practice across the Trust. All staff will have access to evidence based policy and protocols through Intranet access or hard cop where intranet access not available. Local arrangements for healthcare workers to access policy manual communicated by directorate teams. Ward managers / team leaders ensure staff awareness of policy manual format, location and application of evidence based policy to clinical practice. 31 October DIPC / All policies, standards and guidelines are approved by IPCEHC and PSG (Trust policy review group) and disseminated to directorates by DIPC. Audit and regular local compliance monitoring ensure staff are consistently demonstrating safe, effective, evidence informed care. Clinical advisory role provided by IPC nursing team. Increased visibility of IPC nurses in all clinical areas. Frequency of visits dependant on risk rating of individual clinical areas. Development of risk rating tool for individual clinical areas and designation on the risk / confidence matrix dependant on performance and compliance with policy and procedure. 31 October DON Clinical staff held to account for redesignation on the risk / confidence matrix by directorate management team with reports through to IPCEHC. 6
3.0 continued Multidisciplinary IPC audit programme being reviewed. Rolling audit programme in place to measure compliance with key policies. Directorate compliance with key policies and procedures evidenced. Annual audit programme reflecting compliance with Trust priorities articulated in IPC Strategy and Annual IPC programme. Directorate responsibilities with respect to engagement, monitoring and action planning are clearly articulated in annual audit plan. DIPC DIPC Results from rolling audit programme will evidence compliance with all IPC policies and procedures and findings will be reported to IPCEHC monthly by NDL s and by to GMB quarterly Action plans produced to improve compliance and implemented by directorates with IPC nursing support. IPC nurses facilitate action planning and targeted support within areas of responsibility and provide reports re: same at IPCEHC. Quality assurance of compliance with policy and procedures provided by unannounced observations of practice and IPS audits by IPC nurses. 30 October DON Best evidence embedded in clinical practice. (evidenced by internal audit processes, peer review, quality assured by IPC nursing audits and external review bodies) 7
4.0 High Impact Intervention Care Bundles become embedded practice throughout the Trust. RQIA FR 12 All relevant HII s are 31 December DON embedded within clinical areas across the organisation. HII s not currently embedded across the Trust. IPC nurses to facilitate development of Implementation Plan for HII with key stakeholders from directorates outlining individual responsibilities associated with same and associated timeframes. HII data presented monthly to IPCEHC and NET. HII embedded across the Trust. Risks associated with indwelling devices identified and mitigated through use of relevant HII. Clinical ownership of HIIs evident across the organisation. All staff caring for patients with indwelling devices demonstrate 100% compliance with all care elements of HII care bundles as demonstrated by weekly audit data. Any non-compliance with HII s is documented, reported and immediate action taken to address poor practice. Peer review of HII practice within and across operational directorates facilitated by Nurses. 31 December All relevant HII s have been implemented, evidence based practice is embedded and a system to monitor compliance and take action against poor performance is in place. A multidisciplinary HCAI review panel holds individual officers to account for new cases of HCAI. IPC nurses continue to support staff with HII audit process and facilitate clinical practice development to reflect best evidence. IPC nurses audit clinical practice during unannounced visits to clinical areas to provide quality assurance re: robust nature of self assessment. 31 December DON 8
5.0 Surveillance of all alert organisms is enhanced by effective root cause analysis in all C difficile and MRSA / MSSA Bacteraemia cases RQIA FR 13 Alert organisms are reported regionally and monitored by Trust microbiologist. Reported by exception to IPCEHC. Daily monitoring of cases of C Diff and weekly monitoring of MRSA / MSSA bacteraemias. IPCEHC has full understanding of the role of surveillance of alert organisms and can recognise emerging problems at an early stage. Robust data gathering and information management processes embedded to ensure timely data analysis and information dissemination to key stakeholders across the organisation. Benchmark with comparable trusts re: use of information technology systems to manage data flow. DIPC Sustained downward trend in cases of C Difficile and MRSA / MSSA bacteraemias (evidenced by internal reporting mechanisms and external review, trends reviewed against PfA targets Pilot RCA process completed March. Process review conducted and awaiting recommendations to develop action plan. RCA process facilitated by RCA lead with full engagement of clinical teams. Further roll out of RCA training for front line clinical staff. Training needs analysis completed to identify staff requiring training to ensure confidence with process. Delivery of further RCA training for front line clinical staff to be facilitated and evaluated and continued support provided by IPC nurses to facilitate integration of theory into practice. DIPC Lack of ownership of RCA process in clinical areas. Clinical engagement across operational directorates with clarity regarding roles and responsibilities and effective sharing of learning disseminated across the organisation by Governance department. RCA process initiated by clinical teams with facilitation from IPC nurses and quality assurance of data provided by RCAL. Action plans developed by clinical team with accountability for actions and timescales clearly articulated. Process to share learning from RCA s facilitated by Governance department. 31 August 9
5.0 continued Current Position Future State Action by When Timescale Accountable NDL will collate reports on implementation of action plans within the directorate and report on same to directorate governance meetings and IPCEHC. Evidence of RCA data not used to hold individual clinical teams to account. Multidisciplinary HCAI Review Panel holds individual officers to account for new cases of HCAI. Staff held to account for performance of individual clinical area with respect to HCAI prevention. Staff facilitated to reflect on impact of poor clinical practice on patient experience and patient outcome. Staff fully engaged in HCAI prevention. Evidence based policy and procedure integrated into clinical practice and 100% compliance with same. 31 July CEO DIPC DON Zero tolerance principle actioned. Successful application to GAIN to further refine RCA process. Development of a regional RCA audit process. Trust working group established to take project forward. Development of project plan with key stakeholder involvement. 31 March 2010 DIPC Directorates will implement refined RCA process and support dissemination of learning throughout the Trust. 10
6.0 All NHSCT staff are trained and obtain an annual update in IPC. RQIA IR 8 NHSCT IPC Training Strategy developed: induction for all staff mandatory update for all clinical staff mandatory update for nurses using different modalities Training delivery plan for nurses delivered by IPC nurses in collaboration with NEDC. Training delivery plan for other staff groups delivered in collaboration with Organisational Development Team. Continued facilitation of nursing staff to attend training. Induction awareness training for all new staff delivered as part of corporate induction process. A programme of mandatory update for existing staff delivered annually. In place EDON 95% clinical staff will have attended annual IPC update as evidenced by reports from corporate database. currently implementing corporate reporting system to provide overview of uptake for staff groups. Uptake between staff groups varies from very low to very high. Systems embedded in operational directorates to capture IPC training statistics for all staff groups. Compliance with PfA target for annual training of 95% clinical staff. Directorate training statistics highlight where effort needs to be focused to comply with training requirements and action plans developed to ensure compliance is attained. Process for gathering training statistics implemented and monitored within all directorates for all staff groups and forwarded to corporate centre for collation. Collated corporate training statistics will reflect annual PfA target for IPC training. NDL reports re: directorate training statistics at directorate governance meetings and IPCEHC. Reports re: nurse training presented to NET. Corporate training figures reported to Trust Board quarterly. 3 0 September Directorate returns to corporate centre for collation. Directorate action plans to address areas / staff groups where training uptake below target. 11
6.0 continued Low uptake of NHS e- learning programme in infection control. Clinical staff are registered to use the e-learning package. Competency assessment sheets are available as evidence of completion of same. Clinical practice reflects best available evidence. Clinical leads within directorates continue to promote the use of the e- learning package to build on work initiated by IPC nurse during secondment to NEDC. Reports from e- learning administration centre demonstrate sustained increase in level of uptake to projected annual levels required to comply with PfA targets. IPC is a key dimension for review in the appraisal process of all health care staff. Individual PDP reflect learning and development needs linked to HCAI prevention. All staff demonstrate personal responsibility and accountability for reduction in HCAI s. All staff demonstrate commitment to HCAI prevention through integration of evidence based practice and 100% compliance with same. Annual appraisal rates and retrospective review of PDP s and information forwarded to education leads for staff groups to inform training needs analysis. Training tracker for medical staff being implemented in the Trust. Infection prevention and control integrated into consultant appraisals. Medical staff training records transferable across the region Accessibility to training tracker system to enable targeted training for medical staff when working within NHSCT. DIPC Transferability of robust training data across region. 12
7.0 The risk of transmission of infection is minimised through timely isolation and cohorting of infective patients. RQIA IR 5 IR 6 IR 18 FR 11 NHSCT continuously and DIPC systematically reviews, improves and applies best practice in assessment and management of risk to patients, staff and others when patients move from the care of one organisation to another. GAIN Risk Assessment tool completed for all patient admissions / transfers. Isolation Policy in use. Correct and timely placement of infective patients (suspected or proven) to control and minimise the risk of colonisation of other patients in the clinical area. Staff report as clinical incidents avoidable risks to other patients and staff resulting from inappropriate patient placement and delays in securing isolation facilities. Action is initiated by clinical leads and same monitored to minimise chance of reoccurrence. Critical incident reporting initiated when risk assessment forms not completed audit data will identify areas where additional focus is required to ensure compliance. Developed tool to risk assess and appropriately manage single room occupancy and to prioritise the need for isolation facilities at ward level. Isolation risk assessment tool (IRAT) implemented in all departments across the organisation. Trigger list developed to support staff in decision making re placement of infective patients. Decision making by staff quality assured by IPC nurses. IRAT tool rolled out across all acute facilities within the organisation. nurses to continue with roll out of IRAT tool in all acute facilities. IPC nurses continue to support clinical teams with decision making re: patient placement. EDON Robust systems provide evidence that available isolation rooms are used appropriately and where isolation rooms are not available that patients are appropriately cohorted. 13
7.0 continued Harmonising existing legacy NHSCT Bed Management Completion of NHSCT DAS Trust Bed Management policy endorsed by SMT and Bed Management Policy policies. operationalised across the review. Trust. Timely patient placement, isolation and cohorting enabled by continued by partnership working of bed management, IPC and clinical teams. Reports from SOLVER system. Evidence from IRAT data re: appropriate decision making re: isolation / single room occupancy. Review of clinical incident reports when process not managed appropriately. Isolation Ward operationalised in Antrim Hospital, with associated Escalation policy. Daily review of capacity of isolation rooms across Trust complied by Patient Flow team. Clinical incident reporting used to highlight number of occasions on which it is not possible to isolate patients. Regular review and analysis of incident reports by Patient Flow and IPC teams. Isolation ward in Antrim Hospital with associated Escalation policy remains operational. Daily bed management meetings on all acute sites to review capacity of isolation rooms. IPC nurses continue to monitor compliance with local guidelines for isolation facilities during unannounced visits and IPS audits. DIPC 100% compliance with local policies for environmental cleaning, equipment decontamination, waste and linen management demonstrated by clinical and domestic staff within isolation ward. Demand for single rooms outweighs current capacity. New estates will have full compliment of single room accommodation. Options for increasing single room capacity within existing NHSCT estate maximised. Successful implementation of recommendations from Trust Isolation Room Project group. 14
8.0 Antimicrobial prescribing is consistent with best practice. Antimicrobial guidance issued and available on Intranet and on hard copy in all clinical areas. Prudent antimicrobial stewardship evidenced across the organisation. Clinicians demonstrate continued engagement with and commitment to prudent antimicrobial stewardship. In place Compliance with prescribing policy. RQIA IR 4 IR 18 IR 30 IR 31 IR 33 IR 34 IR 35 FR 9 Compliance audited. Audit results sent to DIPC. Audit findings are acted on to ensure continuous improvement Expert antimicrobial stewardship committee led by antimicrobial pharmacist review antimicrobial prescribing against recommendations in local formulary. Clinicians fully engaged compliance results disseminated to clinical directors. Prescribing culture with daily review, de-escalation from IV to oral therapy and maximum duration for antimicrobial therapy embedded across the organisation. Processes for measuring compliance with policy integrated into practice. Processes to address non-compliance with policy have been implemented. Antimicrobial audit fully integrated into annual IPC multidisciplinary audit programme. In place Run charts of compliance with prescribing policy reported through to IPCEHC. 15
9.0 Environmental cleaning will reflect best practice. RQIA FR 14 Daily assurance record In place agreed and signed off by Ward Manager and Domestic Supervisor. Daily cleaning schedule of patient equipment established on each ward. Thoroughly clean buildings across the NHSCT estate. High levels of hygiene and cleanliness maintained. Role of nurse-in-charge as responsible officer for ensuring cleanliness throughout each shift clarified and actioned. Daily cleaning schedule of patient equipment maintained in all clinical areas and departments trustwide and reviewed annually. 100% compliance with local policies for environmental cleaning, equipment decontamination, waste and linen management demonstrated by clinical and domestic staff. Continued partnership working between clinical, IPC and domestic services teams. Annual review of cleaning schedules. In place Public and patient confidence in NHSCT is improved and there are good news stories in the media about the Trust and the HCAI progress which is being sustained. (Client / service user feedback, service user questionnaires, reduction in complaints relating to IPC and environmental cleanliness) Programme for deep cleaning in high and low risk areas established. Deep cleaning programme maintained and evaluated. Regular Dump the Junk sessions. IPC nurses monitor environmental cleanliness and presentation through planned audits undertaken in collaboration with domestic services and estates staff and unannounced visits. In place Clutter free clinical areas as demonstrated by environmental cleanliness audits, IPC audits and unannounced inspections by external agencies. 16
9.0 continued RQIA FR 18 Monthly cleanliness matters In place audits maintained Trust wide with compliance > 85%. Monthly cleanliness matters results disseminated ward to board. Infection Prevention and Control notice boards at entrance to each clinical area demonstrate hand hygiene and environmental cleanliness audit scores. Facilities management provide updates on environmental cleaning to ICC from EHC. Audit data presented to IPCENC and GMB in monthly HCAI report. Systems available to adapt the increased demands of environmental cleaning. Flexibility demonstrated in responding to increased demands of environmental cleaning. Comprehensive guidance re: approval and review of cleaning products. Domestic services continue to monitor and evaluate service responsiveness in collaboration with directorate and IPC teams. Agreed process for introduction and monitoring of new cleaning products endorsed by IPCEHC. DSPMPM Responsive, flexible domestic services system to delver on the increased demands of environmental cleaning. Rapid Response team in place Causeway Hospital. Rapid Response team established Trust wide. Business case prepared and funding secured from commissioner to implement trust wide service. 17
GLOSSARY C Diff Clostridium Difficile CEO Chief Executive DIPC Director of Infection Prevention Control DOH Department of Health DON Executive Director of Nursing GMB Governance Management Board HCAI Healthcare Associated Infection HII High Impact Interventions IPC&EHC Infection Prevention Control and Environmental Hygiene Committee IPC Infection Prevention Control IRAT Isolation Risk Assessment Tool KPI Key Performance Indicator MRSA Methicillin Resistant Staphylococcus Aureus MSSA Methicillin Sensitive Staphylococcus Aureus NDL Nominated Directorate NEDC Nursing Education and Development Consortium NHSCT Northern Health and Social Care Trust PDP Personal Development Plan RCA Root Cause Analysis SMT - Senior Management Team 18