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NHS Lanarkshire Board Meeting 28th January 2015

SUMMARY PAPER HEALTHCARE ASSOCIATED INFECTION REPORTING TEMPLATE

This paper aims to summarise the keys points within the full report. Each summary point is referenced

against the appropriate section found within the full report.

1.1 Key Headlines

Lord Maclean’s inquiry report into the Vale of Leven made 75 recommendations in total, 65 of these were for NHS Boards. Boards were requested to populate and return a template by 19th January 2015 detailing benchmarking progress against the 65 recommendations. NHS Lanarkshire has undertaken a gap analysis of the recommendations against the cateogies defined in the Inquiry Report template. The delivery status collation of the 65 recommendations is outlined below; Not started - 0 Partially implemented -3 Mostly Implemented -33 Fully Implemented – 29 The completed template was approved by the Corporate Management Team and the plan has now been submitted HAI Policy Unit. It is anticipated the Cabinet Secretary will make an announcement in January in terms the next steps. Health Protection Scotland continue to provide updated information on the guidance on caring for patients with Ebola Viral Disease (EVD) as part of the Ebola preparedness planning. Each of the acute sites have instigated operational groups to review the Ebola preparedness planning. Health Protection Scotland report an increased incidence of Influenza throughout Scotland. Boards have been requested to provide information that summarises the point prevalence of suspected and confirmed influenza. This commenced 19/01/2014. A national meeting has been arranged for Carbapenem-Resistant Enterobacteriaceae Screening. Boards are expected to progress this. Details of the meeting and expected board

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actions will be detailed in the next HAIRT update.

Health Efficiency Access Treatment Targets: 1.2 Staphylococcus aureus bacteraemias.

1.3 MRSA Screening

The HEAT target for 2013-2015 is for all Boards to further reduce their rate of Staphylococcus aureus bacteraemias down to 0.24 or less cases per 1 000 acute occupied bed days by year ending March 2015. This is likely to equate to just under an average of 10 SABs in each calendar month for NHSL. NHS Lanarkshire continues to deviate above the planned value on the HEAT trajectory. There were 14, 19 and 13 SAB patients for October, November and December respectively. Health Protection Scotland have not identified NHS Lanarkshire as an outlier Board for SABs. Patients who develop a SAB are subject to enhanced surveillance rapid review. In summary, of the 46 patients identified in Quarter 4, three cases were related to clinical practice issues and a focused piece of work is being progressed by the Infection, Prevention and Control Team to look in detail at practice issues. MRSA Screening remains a major concern for the board as there is a continued failure to demonstrate improvement. In the last 2 reporting periods compliance has remained below 90% at 61% for reporting period 2 (July – September) and 53% for reporting period 3 (October –December). This remains a challenge and discussions with other Boards suggest that this is not unique to NHS Lanarkshire. A reviewed process for MRSA Screening compliance monitoring is currently being tested. The new process will facilitate rapid identification of actions for improvement.

1.4 Clostridium difficile Infection ( CDI)

Across NHS Lanarkshire there were 14 episodes of Clostridium difficile Infection (CDI) in December 2014. Following the CDI Rapid Review process, 8 episodes were categorised as Healthcare Associated and 6 as Out of Hospital CDI. A comparison of the November and December data can be found in the main body of the report. No significant or recurring issues relating to the antimicrobial management of patients have been

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identified during any of the Rapid Review Investigations undertaken. .

1.5 Standard Infection Control Precautions/HAI monitoring (SICPS)

Compliance with PVC monitoring and the decontamination of near patient equipment persist as common themes identified with SICPs and environmental monitoring. These themes are mirrored in the recommendations of the recent HEI Inspections at Wishaw General and Hairmyres Hospitals. To support improvement with PVC monitoring on sites a meeting has been scheduled with the Patient Safety Manager, Head of HAI and the Director of Practice Development to develop a structured improvement plan. In response the HEI Inspection at Hairmyres Hospital the process of SICPS and environmental monitoring has been reviewed, and a longer term plan is being progressed and will align the Lanarkshire process with the Health Protection Scotland SICPs monitoring tool. The interim arrangement was implemented in November 2014 and defines 3 levels outlined below. Level 1 : Senior Charge Nurse will undertake an audit of all 10 elements of Standard Infection Control Precautions (SICPs) and HAI environmental compliance tool. Action plans formulated by the 10th of the month for submission to senior nurse Level 2: Senior nurse will validate and review audits and action plans for their areas of responsibility by the 20th of the month and develop a directorate report for hospital hygiene group Level 3: Infection, Prevention and Control Teams (IPCT) will undertake an audit of SICPs in all ward areas on a six monthly basis and for an HAI environmental audit on a three monthly basis. The detail of the reviewed reporting structure is discussed in the full body of the report.

1.6 Cleaning and Healthcare Environment

NHSL are meeting the required NHSS level of compliance by achieving “green status” i.e. scores above 90% for both Domestic and Estates facilities monitoring. An action plan is in place to address the shortfalls in cleaning standards at Hairmyres as identified during the recent HEI Inspection.

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Senior Management Cleanliness Visits have been scheduled for 2015 throughout NHS Lanarkshire. The visits are led by the Executive Director of Strategic Planning and Performance, Membership of the walk round team includes Infection Prevention and Control Team. An Action plan is generated from the visit and sent to the site Director for completion and return to the Executive Director of Strategic Planning and Performance.

1.7 Healthcare Environment Inspection

The Hairmyres Hospital unannounced inspection report from Tuesday 16th & Wednesday 17th September 2014 and October 03rd 2014 was published on 11th November 2014 along with the NHSL Board Improvement Action Plan. 7 requirements and 3 recommendations were identified. Hairmyres was subject to a follow up unannounced inspection on 13th and 14th January 2015, the report will be sent to NHSL on the 11th February 2015 for factual accuracy and will be published on 11th March 2015. Wishaw General Hospital was subject to an unannounced inspection on the 11th & Wednesday 12th 2014. The report was published on the website along with the Action Plan on Monday 19th January 2015. There were 3 requirements and 1 recommendation identified from this report. Common to both reports is requirements for improvement in cleaning of near patient equipment, PVC compliance monitoring and patient information provision. The full detail of the requirements and recommendations will be discussed in the body of the report.

1.8 HAI Surveillance – Surgical Site Infection (SSI)

The 30 day surveillance period for Quarter 4 will be complete on 30th of January. The data for quarter 4 (October - December 2014) will be available on the 17th February 2015 after the completion of the reporting period. Data collected October - November 2014 in comparison to August –September 2014 has shown a decrease in the SSI rate of caesarean section and repair of neck of femur (hemi arthroplasty) procedures and an increase in the SSI rate for hip and knee arthroplasty procedures. Run charts displaying SSI data over time are

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produced quarterly and distributed to the clinicians and key personnel. To date the data has not shown any astronomical points in the data or trends over time.

1.9 Outbreaks and incidents MRSA PVL Health Protection Scotland was asked to support NHS Lanarkshire with an epidemiological review of increased incidence of cases of Panton-Valentine Leukocidin Meticilin Resistant Staphylococcus aureus (MRSA PVL) type 005. The report generated from this will be the focus of the Incident Management Team Meeting scheduled for 20th January 2015. Vancomycin Resistant Enterococci (VRE) Health Protection Scotland has been supporting NHS Lanarkshire with an outbreak of VRE initially identified in Ward 16 at Monklands Hospital. An initial Problem Assessment Group was convened in December 2014; however this was expanded to an Incident Management Team (IMT) as a result of the Hospital Infection Incident Assessment Tool (HIATT) Watt Group Matrix score of red. The IMT facilitated an epidemiological review of all cases of VRE reported at Monklands hospital since August 2014. To date 8 clinical patient cases have been identified and 7 colonised patient cases. The current HIATT is Amber.

1.10 Norovirus

NHS Lanarkshire has 1 hospital with 1 Bay closed for this reporting period.

1.11 Antimicrobial Prescribing NHS Lanarkshire Antimicrobial Management Team (AMT) continues to progress compliance with CEL 11 antimicrobial prescribing indicators supporting the reduction in CDAD HEAT target by March 2015. NHS Lanarkshire is performing well both locally and in comparison nationally across all acute indicators but continues to be an outlier with respect to the newly introduced primary care indicator, although recent national and local data suggest a reduction in overall antibiotic prescribing volume during 2013/14, the first observed in 5 years. From January 2015 the Healthcare Environment Inspectors will be introducing inspections of Antimicrobial Stewardship throughout Community Hospitals. The Antimicrobial Pharmacy Team continue to work with Infection Prevention and

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Control Nurses in preparedness for this.

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Healthcare Associated Infection Control 28 January 2015 Aim The purpose of this paper is to update Board Members of the current status of Healthcare Associated Infections (HAI) and infection control measures, with particular reference to performance against HEAT targets and cleanliness monitoring Key issues will include

• Staphylococcus aureus Bacteraemias • Clostridium difficile • Hand hygiene compliance • Cleanliness Monitoring • Antimicrobial Prescribing • Outbreaks/Incidents

Other HAI activity such as surgical site surveillance will also feature. Background There is a national mandatory requirement for a Healthcare Associated Infection Control report to be presented to the Board on a bi -monthly basis utilising the template below. There will be an HAI exception report available only where exceptional issues are identified out with the mandatory reporting period.

Summary

This report highlights NHS Lanarkshire performance in relation to infection prevention and control. Site specific Information features in graph format at the end of the report

Recommendation

The Board is asked to note this report.

For further information or clarification of any issues in this paper please contact:

Rosemary Lyness, Executive Director of NMAHP’s, Kirklands, Fallside Road, Bothwell, Tel: 01698 858089

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Section 1 – Board Wide Issues

1.1 Key Healthcare Associated Infection Headlines for October 2014

• Health Protection Scotland continue to provide a situation report and updated information on caring for patients with Ebola (EVD) A case of Ebola (EVD) was diagnosed in a healthcare worker who returned from Sierra Leone on Sunday 29th Teleconferencing was carried out NHS Scotland wide during this time with updates provided and shared learning from the evolving situation

• In December, the Chief Executive NHS Scotland wrote to all board requesting

(territorial and special) them to assess themselves against the 65 Health Board recommendations in the Vale of Leven Report. An NHS Lanarkshire Short Life Working Group was convened to complete a gap analysis. NHS Lanarkshire has scored partially met on 3 of the recommendations. Two of these are in relation to an Infection Control Surveillance System. A short life working group has been established to develop a business case for a suitable system. The third recommendation which was partially met was in relation to the link nurse system and this being progressed via the Care Accreditation and Assurance System work.

• NHS Lanarkshire has site operational groups in place to support Ebola preparedness. These groups meet on a weekly basis. Training sessions have been organised and delivered to A and E staff on all sites on safe removal of Personal Protective Equipment

• The Scottish Government have requested Health Protection Scotland facilitate a

summary of point prevalence of suspected and confirmed influenza. The catalyst to this request is that some NHS Boards have already experienced bed pressures this season from clinical cases admitted with complications of influenza. The dominant strain appears to be Influenza A.

• NHS Lanarkshire continues to collect data for the National Staphylococcus Bacteraemias Surveillance Programme. The data is scheduled to be submitted to Health Protection Scotland for validation in February 2015. Data outputs will be disseminated to Boards after validation has been completed by Health Protection Scotland.

This section of the HAIRT covers Board wide infection prevention and control activity and actions. For reports on individual hospitals, please refer to the ‘Healthcare Associated Infection Report Cards’ in Section 2. A report card summarising Board wide statistics can be found at the end of section 1

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Current HEAT Status

1.2 Staphylococcus aureus (including MRSA)

Staphylococcus Aureus Bacteraemias (including Meticillin Resistant Staphylococcus Aureus): National Report The most recent HPS report on S.aureus bacteraemia was published on 13th January 2015. Lanarkshire had a quarterly rate (July to September) of 34.6 SABs/100000 AOBDs compared to a rate of 32.3 for NHS Scotland as a whole.

NHSL’s LDP HEAT trajectory for the year to September 2014 was 0.25; the actual value was 0.34 (a deviation of 36%).

Staphylococcus aureus bacteraemia cases per 1,000 acute bed days

The target for 2013-2015 is for all Boards to further reduce their rate of Staphylococcus aureus bacteraemias down to 0.24 or less cases per 1,000 acute occupied bed days (AOBD) by year ending March 2015. This is likely to equate to just under an average of 10 SABs in each calendar month. Current Position NHSL National Mandatory SAB enhanced surveillance data collection commenced on the 1st October 2014 for all Boards. Health Protection Scotland data to be submitted and reports sent to Boards. The HAI team are aligning the Rapid Review Process already in place in NHSL at present with the new national data collection tool and protocol. This has triggered a change in local reporting and SABs previously reported as preventable/unpreventable will now be reported as Datixable SABs i.e. a SAB where a clinical practice issue has been identified.

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This will allow further investigation into the individual case as well as allow for shared learning across NHSL. In the quarter Oct – December 2014 there have been 46 SABs in total. Following enhanced surveillance rapid review 3 of the total number of SABs were deemed as to be in related to a clinical practice issue (7%). All 3 SABs were line related (x2 PVC, X1 CVC) and met the criteria for datix reporting. The staff on the wards/depts. where the SAB was associated to will be required to complete an SBAR to investigate the incident and monitor practice where required. All datixable SABs are reported to the site governance groups. All 3 patients were reported at Monklands Hospital. The Infection, Prevention and Control Team is currently investigating this increase in line related bacteraemias and there will progress focused improvement work with an emphasis on line management. Initiatives to reduce Staphylococcus aureus bacteraemias

• The Clinical Quality team are working on aligning the National mandatory data

collection tool into a format compatible with LanQip.

• The SAB Driver Diagram and Change package will be progressed via the Chief Nurses on each acute site and discussed at the Infection Control Acute Sub Group.

• The NES Aseptic module should continually be promoted -

http://nhs.learnprouk.com. This will assist NHSL in reducing the level of datixable SABs and assist in providing best care for patients.

• Focused improvement work to improve line management 1.3 MRSA Screening Compliance The MRSA performance Indicators (KPI) for reporting period was completed in December 2014. MRSA KPI measures compliance with Clinical Risk Assessment (CRA) 53% has been submitted for national reporting to Health Protection Scotland. All wards have received their reports and support with a number of improvement initiatives is provided by the Infection, Prevention and Control Team. Lack of compliance is associated with the delay in the launch of the new Patient Emergency Admission Record, which has the CRA included. This document will make it easier for staff to complete the CRA. This document requires further refinement and testing before it is ready for roll out to all areas. Boards who have achieved the 90% compliance target have included the CRA within the Patient Emergency Admission Record. A MRSA Programme meeting was held on 14th November 2014 for NHSL site nursing leads at which a revised process for MRSA CRA KPI data collection was tabled. This revised process includes named MRSA Champions for admission areas who will undertake spot audits of compliance on a weekly basis and identify areas for targeted improvement. The Infection Prevention and Control Nurse at the Monklands site supported by the Senior Nurse-HAI will

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facilitate this process which will be undertaken prior to completing the data collection for submission at the end of each reporting quarter – this process commenced in January 2015. Completion of the MRSA Clinical Assessment remains a challenge within the Board. Recommendations are as follows:

• Improvement actions for all areas where compliance is below 90%.

• Engagement with MRSA Champions to support revised process.

• Finalisation of the Emergency Care Record including Clinical Risk Assessment.

1.4 Clostridium difficile infection (CDI)

NHS LANARKSHIRE T11.2 Clostridium difficile infections in ages 15+ C.diff infections in patients aged 15 and over per 1,000 total occupied bed days

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at:

http://www.nhsinform.co.uk/Health-Library/Articles/C/clostridium-difficile/introduction

NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/clostridiumdifficile.aspx?subjectid=79

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The revised HEAT target issued by the HAI Policy Unit in September 2013 for 2013-2015 is for all Boards to reduce their rate of Clostridium difficile infections down to 32 or less cases per 100000 total occupied bed days (OCBD) in patients aged 15 years and over by year ending March 2015. NHSL continue to be on target to achieve this projected incidence rate by March 2015. CDI National Reports The most recent HPS report on C.difficile infection was published on 13th January 2015. In NHS Lanarkshire, there was a quarterly rate of 46.1 cases/100000 total occupied bed days in patients aged 15 years and over for July to September 2014 compared to 39.7 cases/100000 total occupied bed days for NHS Scotland. Seasonality has been observed, whereby the pattern in overall quarterly rates in both age groups in 2014 and in the previous four years shows rising incidence rates in Q2 and Q3 followed by a drop over Q4 and Q1. NHS Lanarkshire was not identified as an outlier board for this reporting period. However, NHSL’s LDP HEAT trajectory for the year to September 2014 was 36 cases/ 100000 OCBDs; the actual value was 34 (a deviation of -5.6%). Also detailed within this most recent HPS report the incidence rate for NHSL in patients aged 15 – 64 years is on the the cusp of the funnel charts. During this period there were 22 cases of CDI within this age range. Six cases were reported for Quarter 2 (April to June 2014). This represents an increase of 266% (16 cases) from the previous quarter. For Quarter 3 in 2013 14 cases were reported. Again, this demonstrates a 57% increased in cases in comparison with the third quarter last year. (Caution must be used when interpreting the percentage increase due to the numbers involved). The majority of cases were either community associated or of unknown association or not CDI. Only 27% were associated to Healthcare in NHSL. Work is ongoing with General Practitioners to better understand the increase in CDI within our community. However, no issues have been identified to date. Current Position NHSL Following local enhanced surveillance using the CDI Rapid Review Process there were 14 episodes of CDI throughout NHS Lanarkshire for the reporting period December 2014; 8 were classified as Healthcare Associated and 6 as “Out of Hospital” CDI. In comparison to November 2014, Healthcare Associated episodes decreased from 10 episodes in November to 8 episodes in December and “Out of Hospital” episodes have decreased from 10 episodes in November to 4 episodes in December. No significant or recurring issues relating to the antimicrobial management of patients have been identified during any of the Rapid Review Investigations undertaken Improvement Plan • The Antimicrobial Prescribing LearnPro module for clinical staff is approaching completion.

• Work is ongoing on the development and testing of a Clostriduim difficile quick reference

Guide for staff, and will be tested in December 2014.

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• A patient information leaflet for Clostridium difficile colonisation is now available via Firstport

• Review of the process of severe CDI cases identified to ensure timely and meaningful root

cause analysis is undertaken and shared learning is supported. • All recommendations and lessons learned from Rapid Review Investigations will continue

to be shared via the existing Hospital & Board Patient Safety and Quality Improvement Committees

Section- 1.5 Standard Infection Control Precautions (SICPs), HAI monitoring:

SICPs and HAI Environmental Compliance Monitoring Common Themes The common themes identified from the IPCT Quality Assurance audits from the acute sites for the month are reported below

SICPs • No documented risk assessment in place if patient can’t be isolated • If in isolation door not closed/ no risk assessment if can’t be closed • Inappropriate waste segregation • Inappropriate use of PPE

HAI Environmental Compliance Monitoring

• Near patient equipment dusty and not visibly clean particularly sharps trays, raised toilet seats and beds

• Cleaning schedules not completed • Bread not being stored in bread bin/bread bins broken • Kitchen extractors not visibly clean • DSR Rooms unclean/not locked • Equipment and stock on the floor • PVC Insertion and maintenance bundles incomplete

On comparing the common from the ICPT Quality Assurance audits to the SCN there are similarities within the thematic however more issues are identified from the Quality Assurance Audits. To ensure consistent approach the Senior Nurse-HAI will undertake walkrounds with the onsite Senior Nurses.

The common themes identified from Primary Care for the month of November have been reported below.

• Cleaning schedules not signed off by the Senior Charge Nurse

Current reporting format has to be revised and a more detailed report tabled at the next Joint CHP Infection Control Committee.

Revised Monitoring and Reporting

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As a result of the unannounced HEI visit at Hairmyres hospital a revised interim monitoring process for Standard Infection Control Precautions (SICPs) and HAI Environmental monitoring in NHS Lanarkshire took effect from the 1st November 2014. The Senior Charge Nurses from all in-patient areas now undertake a full Standard Infection Control Precautions and HAI Environmental Compliance Tool Audit on a monthly basis. The Senior Nurse for the relevant area will validate and review the audits and will agree upon the action plan for their areas of responsibility by the 20th of the month. The Infection Prevention and Control Team will undertake a Standard Infection Control Precautions audit in all inpatient areas over a 6 month period. The HAI environmental monitoring audit will be undertaken 3 monthly.

Thematic reports have been developed by the Infection Prevention and Control Teams and Senior Nurses for the Hospital Hygiene Group. The findings of these reports are shared at the site Patient Safety and Quality Improvement group chaired by Chief of Medical services and at the Hospital Management team meeting chaired by the Hospital Site Director. To ensure robust reporting and discussion of SICPs is on the Agenda, the Terms of Reference for the HEI Steering Group has been reviewed. The new format was tested in January 2015 and some modification is required to the agenda. The interim monitoring mechanism will remain in place until the launch of the new SICPs monitoring tool, which is based on the Health Protection Scotland SICPs Monitoring Tool. The HAI Team and Clinical Quality Team are working closely on the development of this tool. A firm work plan has been developed and progress is updated weekly. The launch date for the new tool is May 2015. Hand Hygiene Monthly Quality assurance audits continue to be undertaken out by Acute site ICNs. The results in the graph below have demonstrated an overall increase in compliance amongst the 3 acute sites for the month of November is 95%. The overall NHSL hand hygiene quality assurance compliance rate is 95% which is meeting the national target.

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Monthly Hand Hygiene self reporting for SPSP have demonstrates compliance amongst all groups. Compliance remains static over time. This data is self reported by ward areas.

1.6 Cleaning and the Healthcare Environment

• Facilities Monitoring Tool (FMT) Performance Scores for Domestic and Estates

The current status reported nationally, shown in the table below, demonstrates that NHS Lanarkshire (NHSL) continues to achieve the required cleanliness standards across the Acute and CHP locations. NHSL meets the NHS Scotland Facilities Monitoring Tool level of compliance by achieving “green status” i.e. scores above 90% for both Domestic and Estates. The Domestic Standards score for Hairmyres has dropped from 96.3% in quarter 2 (July – September) to 91.9% in quarter 3 (October – December) reflecting the observations of the HEI Inspectorate. It should be noted that any quarterly deviations in performance standards should be viewed with caution. In line with the National Monitoring Framework, areas are audited dependant on the specification code associated with clinical risk & the prescribed monitoring frequencies.

NHSL Quarterly Comparison – Domestic & Estates

Locations Quarter 2 Quarter 3 July-Sept 2014 Oct-Dec 2014

Domestic Estates Domestic Estates

Aug-14 Sep-14 Oct-14 Nov-14

AHP 93

96

97

99

Ancillary 94

94

97

97

Medical 95

95

94

96

Nurse 98

98

98

98

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at:

http://www.hfs.scot.nhs.uk/online-services/publications/hai/

Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at:

http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

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Acute Monklands 94.9% 97.5% 94.7% 96.6% Hairmyres 96.3% 98.4% 91.9% 96.3% Wishaw 95.6% 96.4% 96.3% 96.1%

CHP Airdrie/Coatbridge 97.1% 97.6% 97.8% 97.2% Cleland/Motherwell 96.1% 98.4% 96.8% 98.4% Hamilton/EK 95.2% 96.6% 96.5% 96.1%

• HEI Visits

Hairmyres and Wishaw General Hospitals received unannounced HEI visits during quarter the detail

Hairmyres Hospital The HEI Inspectorate carried out an unannounced inspection at Hairmyres Hospital on Tuesday 16th & Wednesday 17th September 2014. The detail of this will be discussed in Section 1.7. Monklands and CHP Sites The quarterly results for these sites continue to be consistent; PSSD managers are working closely with site Control of Infection and Nursing teams in participation of HEI and SIPPS audits process. • Senior Management Cleanliness Inspections/Visits

As a result of the unannounced Healthcare Environment Inspectorate (HEI) visit at Hairmyres Hospital on the 16th and 17th of September 2014, NHSL was tasked with providing clear assurance to the public and the board that sound systems and processes are in place in for Healthcare Associated Infection (HAI) and environmental monitoring. One of the actions from this has been to develop a schedule of Senior Management Cleanliness site visits. This work is intended to further support consistency across the board and offer transparency of processes across a number of services. This process is now underway and Wishaw was visited on November 11th 2014 with a follow up visit on November 28th 201.and Monklands visited on December 30th 2014. General compliance was noted, however in each case, a report was produced and shared with Site Directors. Site Directors were asked to confirm that noted required corrective actions be completed timeously following these unannounced inspections.

• Bagging & Tagging Update (West of Scotland Laundry

The bag labelling & segregation still does not comply fully with NHSL’s Control of Infection Manual Section D1 – Laundry. The results of the most recent audit carried out in the WoSL during October and compared against June 2014 are shown in the chart below:

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PSSD - West of Scotland Laundry: Linen Labelling/Bagging Audit Audit Completed: October 2014 (Comparison to June 2014)

Bag Labelling Linen Segregation

Area

Total Bags Audite

d

% Complia

nt

Previous Audit (June '14)

Compliance Versus June '14

(+/-)

%

Compliant

Previous Audit

(June '14)

Compliance Versus June '14

(+/-) Total: Lanarkshire 3740 78.4% 77.9% 0.5% ↑ 96.3% 95.3%

1.0% ↑

Total: Ayrshire & Arran 3010 69.3% 51.5%

17.8% ↑ 93.7% 92.9%

0.8% ↑

Dumfries & Galloway 1009 71.4% 73.2% -1.8% ↓ 93.7% 93.6%

0.1% ↑

State Hospital 95 95.8% 89.6% 6.2% ↑ 97.9% 95.1% 2.8% ↑

Overall Consortium 7854 74.2% 66.5% 7.7% ↑ 95.0% 94.2%

0.8% ↑

The following actions are currently in progress: • Action plans and initiatives have been introduced at NHSL, A&A, D&G and State

Hospital. These must be followed up locally and performance levels monitored for required improvement.

• The introduction of a Laundry and Nursing video is planned for completion by end of Q4. • A Learn-pro module for nursing staff is to be introduced by NHSL senior nursing and

shared with consortium members Summary A report issued on 19th February 2014 to the NHSL Board of Directors highlighted the continued risk to the safety of laundry staff due to non compliance with National Infection Prevention and Control Manual. Recommendations within this report included a joint working approach from all Consortia members sharing “best practice” improvements and the introduction of a SLWG with Laundry, Infection Control and Health & Safety Management, reporting to the West of Scotland Laundry Board. Despite the above recommendations being carried out and subsequent improvements, the current conformance figures still fall short of the 100% compliance standard required. An updated report and timeline will now be progressed by the General Manager of Property and Support Services to the NHSL Board advising of the current status and work completed and in progress. The report will also request that, should these “in progress” initiatives not satisfactorily address the compliance standards required, this should be escalated to the Corporate Risk Register and further corrective action recommended.

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The Director of Nursing for the Acute Division has re convened the Short Life working Group for Laundry to ensure all agreed actions and timescales are met.

1.7 Healthcare Environment Inspections. The Hairmyres Hospital unannounced inspection report from Tuesday 16th & Wednesday 17th September 2014 and October 03rd 2014 was published on 11th November 2014, with the NHS Lanarkshire Improvement Action Plan. There were 7 requirements and 3 recommendations identified, the report has been published and the Board has previously been appraised of these. The focus of the Hairmyres inspection was both cleaning of near patient equipment and environmental hygiene. The action plan has generated focused activity in these areas including a full review of current SICPs monitoring as previously mentioned. The 16 week update on the action plan is due to be returned on Thursday 22nd January 2015. The action plan continues to be pro actively managed. Hairmyres was subject to a follow-up unannounced inspection on 13th and 14th January 2015, the report will be sent to NHSL on the 11th February 2015 for factual accuracy and will be published on 11th March 2015. Wishaw General Hospital was subject to an unannounced inspection on the 11th & Wednesday 12th 2014. The report was published on the website along with the Action plan on Monday 19th January 2015. There were 2 requirements and 1 recommendation identified from this report Requirements

1. NHSL must ensure that where a peripheral vascular catheter (PVC) is in place, staff adhere to local policy and complete the accompanying care bundle documentation. This will reduce the risk of infection to patients, staff and visitors.

2. NHSL must ensure that all patient equipment is clean and ready for use. This will reduce the risk of cross-infection to patients, staff and visitors

3. NHSL must ensure that HAI information is effectively disseminated to patients, relatives and carers. This will ensure that all patients are fully informed about the prevention and control of infection

Three of the recommendations were similar to Hairmyres with compliance of PVC monitoring, cleaning of near patient equipment and patient Information review recommended. 1.8 Outbreaks/ Incidents NHS Lanarkshire IM&T MRSA PVL Health Protection Scotland was asked to support NHS Lanarkshire with an epidemiological review on an increased incidence of cases of Panton-Valentine Leukocidin Meticillin Resistant Staphylococcus aureus (MRSA PVL) type 005. An Incident Management Team was convened

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on September 2014 to facilitate reporting from the epidemiological review. The next IMT will take place on the 26th of January 2015. At this group the final Health Protection Scotland epidemiological report will be presented and discussed and recommendations followed up as required. Following the initial findings and as part of the ongoing investigations, NHSL has identified the need for a robust alert organism local surveillance system to measure and report levels of MRSA and monitor new acquisitions at ward and hospital level to be implemented as soon as possible. This would also be in keeping with a key recommendation of the Vale of Leven report. NHS Lanarkshire IM&T Vancomycin Resistant Enterococci VRE Health Protection Scotland has also been supporting an investigation into an outbreak of Vancomycin Resistant Enterococci (VRE) in Ward 16 at Monklands Hospital. This incident scored HIIAT Red on the Watt Group Matrix. An IMT was convened in December 2014 to support an epidemiological review of all cases of VRE reported in Monklands Hospital since August 2014. To date 8 clinical patient cases have been identified and 7 colonised patient cases. Of the patient samples sent for typing two patient cases who had clinical infections with VRE and were reported as identical in profile. Two further patients colonised with the same organism was identified with the identical profile as the two clinical infections; a third case had an almost identical profile as the aforementioned four cases. Scottish Government have been updated on the situation and the current HIATT is scored as Amber. The next IMT is scheduled for February 2015. 1.9 Norovirus This Monday 12/01/2014 in NHS Scotland there were 2 hospitals with 2 wards closed and 0 Bays closed for this reporting period. NHS Lanarkshire had 0 hospitals with 0 wards and 0 Bays closed or affected. Other HAI Related Activity 1.10 Surgical Site Infection (SSI) Surveillance The data for quarter 4 (October - December 2014) will be available on the 17th February 2015 after completion of the reporting period. This allows for completion of the full 30 day surveillance reporting period for December. Caesarean Section (CS) Mandatory Surgical Site Infection (SSI) Surveillance Data October – November 2014 The data for October – November 2014 has demonstrated a decrease in the SSI rate from 1.1% (n=3) in August – September 2014 to 0.4% (n=1) and equal to 0.4% (n=1) in October – November 2013. The number of the procedure undertaken October – November 2014 has decreased by 2.26% from August – September 2014 and increased by 8.4% compared to October – November 2013.

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A clinical review was undertaken on the patient who developed a superficial SSI. The patient was noted to have a number of recognised risk factors for SSI including, had a very high BMI, prolonged surgery and a high incision. No trends have been identified from the twenty four months of data provided in the run charts. The maternity improvement group meetings are currently being rescheduled. Orthopaedic Mandatory Hip Arthroplasty SSI Surveillance Data October – November 2014 The data for October – November 2014 has demonstrated an increase in the SSI rate from 0% (n=0) in August – September 2014 to 1.5% (n=1) and increased from 1.3% (n=1) from October – November 2013. The number of procedures undertaken October – November 2014 has decreased by 15.2% (from August – September 2014 and 14.1% from October – November 2013. On average Hairmyres undertakes 50% of all hip arthroplasty procedures in NHSL. A review was undertaken on the patient who developed a superficial SSI post discharge at Hairmyres hospital. There were no significant issues noted. This is the first SSI identified as part of hip arthroplasty mandatory surveillance at Hairmyres Hospital since December 2013. The run charts currently display data points for 24 months and no trends or astronomical points have been identified. Voluntary Repair of Neck of Femur (Hemi arthroplasty) SSI Surveillance Data October – November 2014 The data for October – November 2014 has demonstrated a decrease in the SSI rate from 1.8% (n=1) in August – September 2014 to 0% (n=0) and a decrease from 2.9% (n=2) in October – November 2013. The number of procedures undertaken October – November 2014 has increased by 22.8% from August – September 2014 and increased by 1.5% compared to October – November 2013. Wishaw General Hospital undertakes on average 30% more hemi arthroplasty procedures than the other hospitals in NHSL. No trends have been identified from run charts provided for the quarterly reports displaying two years of data. Voluntary Knee Arthroplasty SSI Surveillance Data October – November 2014 The data for October – November 2014 has demonstrated an increase in the SSI rate from 2.1% (n=2) in August – September 2014 to 3.3% (n=3) and an increase from 0.8% (n=1) in October – November 2013. The number of procedures undertaken October – November 2014 has decreased by 7.2% from August – September 2014 and decreased by 25.6% compared to October – November 2013. Hairmyres Hospital undertakes approximately 50% of all knee arthroplasty procedures in NHSL.

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A review was undertaken by the surveillance nurse on 3 patients who had knee arthroplasty performed in October at Hairmyres hospital and who subsequently developed an SSI. Two superficial and 1 was deep infections were identified. No links were identified in time or person and the review did not highlight any areas for concern. All cases were discussed with the Consultant Microbiologist and were no issues or concerns microbiologically. The length of procedure is a recognised risk factor for SSI and 1 patient’s procedure time exceeded 2 hours. An SBAR detailing these cases was completed and tabled at the HAI sub group meeting. No trends have been identified from run charts provided for the quarterly reports displaying two years of data. HAI Surveillance Activity

• Future activities for the HAI surveillance nurses will include following the orthopaedic patients’ journey from pre-assessment, to admission, during surgery and in the post operative period. This exercise will be repeated with patients undergoing elective caesarean section procedures.

• Orthopaedic assurance group meetings will convene again this year with the intent to

discuss issues and improvements to be made. Monklands will hopefully come on board this year with an orthopaedic assurance group.

1.11 Antimicrobial Prescribing: NHS Lanarkshire Antimicrobial Management Team (AMT) continues to progress compliance with CEL 11 antimicrobial prescribing indicators supporting the reduction in CDAD HEAT target by March 2015. NHS Lanarkshire is performing well both locally and in comparison nationally across all acute indicators but continues to be an outlier with respect to the newly introduced primary care indicator, although recent national and local data suggest a reduction in overall antibiotic prescribing volume during 2013/14, the first observed in 5 years.

National Scottish Antimicrobial Prescribing Group (SAPG) CDAD HEAT prescribing indicator reports for acute indicators show:

• Compliance with policy in medical admission units > 95% (data from April 2011- March

2014) - met by 4/14 boards - NHSL one of them – NHSL median compliance was 98%

[n=1748] against a national median of 93% [n=14804]

• Compliance with policy in surgical admission units > 95% (data from April 2011- Sept 2013)

- met by 5/14 boards - NHSL one of them – NHSL median compliance was 100% [n= 905] against a national median of 90% [n=8944]

• Compliance with policy in Surgical/prophylaxis > 95% (data from April 2011- Sept 2013)

- met by 7/14 boards - NHSL one of them – NHSL median compliance was 100% [n=1193] against a national median of 93% [n=6761]

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National level 3 antibiotic indicator data for primary care based on volume of antibiotic items prescribed against a nationally agreed set target has been released. The indicator target is for 50% of NHS Board GP practices to be in the lowest quartile of prescribing practices across Scotland based on period Jan-March 2013 or have made good progress towards achieving that level.

• NHSL data for 2013/14 indicates a reduction in antibiotic prescribing in 38 of the 96 NSHL GP practices in those respective Jan-March quarters of 2013 and 2014. Another 7 of NHSL GP practices were within the lowest quartile of Scottish prescribing volume in Jan-March 2014, leaving NHSL approximately 3 GP practices short of attaining the national target set by SAPG for 2013/14.

• The latest annual SAPG Primary Care Prescribing Indicators report published October 2014 also shows a reduction in NHSL primary care prescribing for the first time in 5 years and to the lowest level in that 5 year period (although still significantly above the national median) giving encouragement that the year on year increases observed within NHSL since 2009 may be reversible with the right blend of focus and resource.

• NHSL AMT continues to work with Senior GP management and the NHSL Primary Care Prescribing Team to identify high prescribing practices in an effort to reduce inappropriate prescribing, particularly for upper respiratory self limiting infections. A suite of validated materials produced to redress patient expectations around antibiotic use are now being cascaded to GP surgeries, community hospitals and out of hours GP centres by the Prescribing Management Technician Team. Face to face sessions at GP practice, locality forum, out of hours and community hospital prescribing team level will continue to be delivered through 2014/15 to consolidate and build on the progress observed to date.

• European Antibiotic Awareness week events were delivered successfully across NHSL acute sites and primary care during November and included use of social media and staff intranet to promote a national Antibiotic Guardian campaign pledges from NHSL staff, patients, allied health professionals, and members of the general public. Community

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Pharmacies and Dentist contractors were included in cascade of tailored materials this year for the first time to ensure consistency of message around prudent appropriate antibiotic usage.

From the beginning of January 2015, the Healthcare Environment Inspectorate (HEI) will be introducing inspections of antimicrobial stewardship to all community hospital inspections. The inspectorate has been working with the Scottish Antimicrobial Prescribing Group (SAPG) and the “Association of Scottish Antimicrobial” Pharmacists (ASAP) to ensure robust inspection is implemented to meet Scot MARAP 2 (2014) and SAPG guidance. Inspectors will be looking for clear evidence of antimicrobial management team’s stewardship of community hospitals, and availability and implementation of antimicrobial policies. The Anti Microbial Prescribing Pharmacy Team have been working with the Primary Care Infection Control Nurses.

Section 2 – Healthcare Associated Infection Report Cards

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