nhs tayside infection control

Infection Prevention and Control Scorecard Strategy 09-10 FINAL[2].doc of 47

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NHS Tayside

INFECTION CONTROL

Infection Prevention and Control Scorecard Strategy 2009/10

Information for Clinical Groupings including CHPs

Author: Gabby Phillips Review Group: Infection Control SMT

Review Date: June 2010 Last Update: June 2009

Document No: Issue No: UNCONTROLLED WHEN PRINTED

Signed: Executive Lead (Authorised Signatory)



Contents Page number

1. Summary 3

2. Background 3

3. Aims 3

4. Objectives 3

5. The Scorecard 4

6. Goals for each scorecard target area from January 2009

5-7

7. What Clinical Groups Need to Do 8

8. Areas for Scorecard Monthly Monitoring of Wards and Aggregated Groupings

9

APPENDIX 1: Scorecard May 2009 10-17

APPENDIX 2 - SGHD HAI Action Plan RAG Report (June 2009 Response)

18-22



1. Summary The Healthcare Associated Infection (HAI) Strategy will incorporate the key priority areas as outlined in the balanced scorecard. Clinical groupings including CHPs will receive scorecards on a monthly basis along with access to the raw data, clearly marked with their position and goal. A balanced scorecard will be to achieve 'green status' in all areas. The finding of amber or red will trigger a response for investigation and action. The Infection Control team will support staff to help find solutions. The Divisions Joint Clinical Boards are asked to re view progress with the National & HEAT targets :

• Zero tolerance for hand hygiene compliance in all s taff groups • Staph aurerus bacteraemia reduced to 146 new episodes for

NHS Tayside by the end of March 2010 • Clostridium difficile reduction (30% by 2011 from 1.64 to 1.07

episodes per 1000 Total Occupied bed days) by 2011 Progress is monitored monthly by the Waiting Times performance group, Delivery Unit Management team, Acute delivery Unit Clinical Governance Group, the Board and the HAI Network meetings 6 times per year. In addition figures are scrutinised by Taystat, Chairman’s meeting with the SGHD, local Clinical Governance/Risk Management meetings in CHPs. Data are presented at Board meetings and available to the public. Please check: are you

1. receiving the relevant data? If not please contact Infection Control Office 32138

2. sending the relevant data? (non returns are scored as red) 3. reviewing the HEAT and National HAI Targets and progress

regularly? 4. taking actions and monitoring outcomes as needed?



2. Background The HAI agenda is wide ranging and often complex. It underpins many activities in every area of healthcare from management to hands-on healthcare, and includes clinical and non-clinical staff. NHS Tayside has a single combined delivery of the infection control service across primary and secondary care. Because of the wide ranging remit, focus is on 'high impact' areas where there are good data, surveillance systems and opportunities for interventions that will lead to measurable improvements in place. Other areas and issues will continue to be worked up and managed as listed in the HAI Annual Programme/Improvement Plan. All Clinical groupings including CHPs will still be subject to audits and are expected to continue with their own HAI Action Plans. 3. Aims The aims of the HAI strategy are to

• continue to improve the health and safety of staff, patients and visitors

• sustain those improvements that have already been made • meet the Nationally set targets for C difficile cases, hand hygiene

and staphylococcal bacteraemia and antimicrobial prescribing as well as our locally set targets for other key areas

4. Objectives ♦ to meet national HAI and HEAT targets ♦ to met local HAI targets ♦ to reduce HAI in NHS Tayside with high impact interventions in key

high risk areas ♦ to engage clinical staff in these improvement goals ♦ to produce a format which is simple and easily understood,

reproducible ♦ to continue improvements across the single delivery unit healthcare

sites

Infection Prevention and Control Scorecard Strategy 09-10 FINAL[2].doc Page 1 of 47


5. The Scorecard

1

Hand Hygiene

compliance

2

Antimicrobial

Prescribing

3

Sharps Injuries

5

SSI

Education

4

HAI S aureus

bacteraemias

VAP

6

Environmental

Cleaning

7

CVC associated

infections

8

New

MRSA acquisition

9

New

C. difficile acquisition



Beneath each area will be some or all of the following: Goal definition, data collection, display frequency and analysis, bundles, management and reporting systems, policy, procedures, education, training, audit, surveillance, action plans and various groups that work on improvements. For each domain an 'NHS Tayside Good Practice Guideline' is available on request form the infection control office (32138). Non returns of information will be defaulted to 'red'. For clinical groupings including CHPs where areas are amalgamated, the lowest/worst result will be the one submitted (ie if 4/6 wards have achieved green, 1 has achieved yellow and 1 is red, it will be the red one that is put forward for the scorecard). HAI = Healthcare Associated Infection VAP = Ventilator Associated Pneumonia SSI = Surgical Site Infections CVC = Central Venous Catheter For S.aureus bacteraemia, new MRSA acquisition and new c.difficle acquisition the data for acute clinical groupings will be amalgamated and presented as run charts with individual ward or department data presented in table format with status highlighted as red, amber or green.



6. Goals for each Scorecard Target Area from Januar y 2009 1. Zero tolerance to non compliance with Hand Hygiene

standards. Audits performed on monthly samples of 2 0 staff made up of 10 nurses, 3 medical staff, 4 Allied Hea lth Professionals, 3 ancillary staff. The monitoring i s based on the 'WHO 5 points' and on technique using existing tool s. > 95% compliance = green < 95% compliance = red Wards will supply data monthly to Infection Control Teams using the data they already collect for the SPSP programme where possible. This needs to be with the Infection Control Office by the 7th of each month.

2. (i) Orthopaedics arthroplasty prophylaxis complianc e with 3 dose regimen.

95-100% compliance = green 80 - 94% compliance = yellow <80% compliance = red Surveillance ICN to provide prophylaxis data. (ii) Compliance with empiric antibiotics policy: M edicine NW, Medicine PRI, Surgery NW, Surgery PRI, RVH - base d on compliance data collection by pharmacists in acute admission areas and RVH wards. 95-100% compliance = green 80 - 94% compliance = yellow <80% compliance = red (iii) Compliance with empiric antibiotic policy: PRI and Stracathro MfE wards based on restricted antibiotic usage as a % of total usage 0 -10% = green 11 - 15% = yellow >15% = red



(iv) CHP, Critical Care and Haematology/Oncology i ndicators to be developed in due course. Boxes will remain b lank until then.

3. Number of Sharps injuries per clinical grouping/CHP is reduced . (this includes needlesticks and other injuries) 0 = green 1 = yellow 2 = red Results will be taken from Adverse Incident Management data base of electronically reported incidents collated by Infection Control Team.

4. ↓↓↓↓ 35% by 2010 in Hospital Acquired S aureus bacteraemias (MSSA & MRSA) from March 2006 to 146 episodes per a nnum by March 2010. We need to reduce by 51 episodes ov er the coming year to achieve this target 0 episodes per month per ward = green 1 episode per month per grouping = red Ward/unit/hospital acquired if patient in ward >48 hours from date of blood culture positive sample. 'Back allocation' will be performed if <48 hours from admission to date of positive blood culture. Infection Control Team (ICT) will supply data monthly

5. a) Ventilator Associated Pneumonia rates to be reduced* <15/1000 ventilator days = green 16-29/1000 ventilator days = yellow >30/1000 ventilator days = red ITU will supply data monthly (Dr Sally Croft/Dr I Mellor for NW) OR b) Surgical Site Infection rates to be reduced

♦ Breast* <4.9% (green) 5-6.9% (yellow) >7% (red) ♦ Caesarean section*, total abdominal hysterectomy* and

fractured neck of femur* <4.9% (green) 5-9.9% (yellow) >10% (red)



♦ Total hip and total knee replacements * <1.5% (green) 1.6-4.9% (yellow) >5% (red): {deep infections <1.5% }

♦ Vascular <9.9% (green) 10-14.9% (yellow) >15% (red) *includes post-discharge surveillance Supply of data as per current surveillance system OR c) Education. Number of Cleanliness Champions on th e Ward

per month*

>4 Champions on ward = green 3 Champions on ward = yellow < 2 Champions on ward = red Mrs F Main will provide data on a monthly basis. *These data need to be with the Infection Control Office by the 7th of each month

6. Environmental cleaning. Areas to be in green zone u sing the

Domestic Services Monitoring Tool. Domestic services will alert any red or amber in the groupings given below per month. Data will be provided by Chris Gordon, Elizabeth Proudfoot and Billy Thomson. These data need to be with the Infection Control office by the 7th of each month. If results are anything but green the Infection Control team will liaise with Domestics Services for further action and a discussion at the next Performance meeting

7. Central Venous Catheter infection rates to be reduc ed in the following areas Renal (RDU/22), Surgery (7-12/HDU), Ward 20,Haematology/oncology. < 3/1000 catheter days = green 3.1 - 4.0/1000 catheter days = yellow >4/1000 catheter days = red



Supply data monthly as per current systems These data need to be with the Infection Control Office by the 7th of each month Any other area is welcome to put forward data that they are collecting for this

8. Reduce new MRSA acquisitions, recorded per Month pe r Ward in line with trigger tool and SGHD new reporting te mplate 0 new cases = green 1 – 2 new cases in any ward = yellow > 3 new cases in any ward = red All wards with overnight stay in groups as below based on current local screening policy. In groups of more than one ward, the highest ward score will be the one put forward for the scorecard. Ward acquired if patient has been in unit >48 hour prior to first detection. ‘Back allocation’ done on basis of knowledge of MRSA status of the last ward/unit/hospital patient was in within past month as per current system ICT will supply data monthly

9. Reduce new C. difficile acquisitions, recorded per Month per Ward in line with trigger tool and SGHD new reporti ng template 0 new cases = green 1 – 2 new cases in any ward = yellow > 3 new cases in any ward = red Wards with overnight stay in groupings as below based on current testing protocol. Ward acquired if patients has been in >48 hours prior to onset of symptoms ‘Back allocation’ done on basis of knowledge of Clostridium difficile status of the last ward/unit/hospital patient was in within past three months as per current system ICT will supply data monthly



10. Compliance with PVC Bundle, CVC Maintenance Bundle & CVC Insertion Bundles

> 95% compliance = green 80 – 94% compliance = yellow < 79% compliance = red Testing = white Data provided by Diane Campbell’s team These data need to be in the Infection Control Office by the 7th of each month

11. Alert conditions, Organisms that are reported withi n 24 hours to ICT/the total number identified

100% = green 49 - 99% = amber >50% = red

12. Environmental audits feedback. The number of audit s fed back within the agreed timescale

>95% = green 49 - 94% = amber <50% = red

7. What Clinical Groups Need to Do You will receive the following data from the Infection Control Team for monitoring purposes: 1. New cases of MRSA and Clostridium difficile (HEAT target) for

individual wards . The trigger is 2 or more new cases within the previous 30 days. Weekly data are supplied to wards, managers and senior clinical staff. Please distribute as you see fit, remembering your junior medical staff. Infection Control will help support and investigate any triggers and work with you on any remedial actions.



These are supplied weekly and monthly and it is expected that they will be reviewed at your local Clinical Governance meetings or other relevant meetings to ensure that the National and HEAT targets are met. A chart of weekly snapshot of unisolated cases is circulated.

2. Scorecards .

To give an overall picture of how your clinical grouping fits in to the NHS Tayside picture and to ensure a balanced approach is taken to the wider aspects of HAI.

3. Staphylococcal bacteraemia (HEAT target)

All cases will have a rapid review by the Infection Control Team and members of the clinical team that are available. These will be colour coded (red, amber, green) in terms of whether they are preventable. Consultants are free to make further comments and are asked to help make sure that everything is done to prevent further cases.

4. Monthly hand hygiene audits [National target: ze ro tolerance

CEL 5 (2009)] These are already undertaken as part of the SPSP. It is expected that these data are reviewed at Clinical Governance meetings or other relevant meetings to ensure that National and zero tolerance targets are met. Remedial action must be taken if required

8. Areas for Scorecard Monthly Monitoring of Wards and Aggregated Groupings 1) Ninewells (admission wards not included)

1. medicine/cardiovascular 1-6 2. medical (others) 14, 14HDU, 21, 42, CIU 3. surgery 7-12/HDU 4. renal RDU/22 5. ward 20 6. orthopaedics 16-19 7. haematology/oncology 32 /34 8. ward 31



2) PRI (admission ward not included) 1. ward 1 2. wards 3&6 3. ward 5 4. wards 7&8 5. Tay, Earn and Stroke wards 6. ITU 7. RDU

3) Stracathro

1. Ward 2 2. Ward 3 3. Surgical Unit 4. Stroke unit

4) Royal Victoria Hospital

1. Ward 1 2. Ward 2 3. Ward 3 4. Ward 4 5. Ward 5 6. Ward 6 7. Ward 7 8. Ward 8 9. Roxburgh East 10. Roxburgh West

5) CHP

1. Dundee CHP 2. Angus CHP 3. Perth & Kinross CHP

Other areas not on the scorecard will continue to be monitored as part of the routine surveillance/audit and infection control programme and especially action is required in relation to hand hygiene. G Phillips Lead Infection Control Doctor February 2009



APPENDIX 1: Scorecard May 2009

Scorecard Results as per Directorate, Ninewells Hos pital May 2009

Medical

Surgical

Orthopae

dics

Ward 20

Renal

Haem/ Onc

Ward 31

Medical (14,14HDU,21,

CIU,42)

Target

Hand Hygiene Compliance

80 (90)

70 (70)

71 (85) 95

(95)

95 (90)

95 (90)

100 (100)

95 (90)

> 95%

Awaiting

Antimicrobial Prescribing

No data (80)

No data

(50) (100)

No report

(No report)

No

report (No

report)

No report (No report)

No data

(80)

No data

(80)

> 95% (Orthopaedics

– Antibiotic Prophylaxis,

All other areas – Empirical Prescribing)

Sharps Injuries

1 (1)

0 (0)

1 (0)

0 (0)

0 (0)

0 (0)

1 (0)

1 (0)

0

HAI S. aureus Bacteraemias

See separate tables below 0 (0)

1 (1)

0 (0)

0 (0)

1 (0)

0

Education 1 (1) 1 (2) 4 (4) 7 (7) 17 (17) 2 (2) 2 (3) 0 (0) > 4 Environmental Cleaning

100 (92)

100 (92)

100 (94)

100 (97)

100 (93)

100 (94)

100 (97)

100 (93)

> 90%



New MRSA Acquisitions

0 (1)

1 (1)

1 (0)

0 (0)

1 (0)

0

New C. Diff Acquisitions

See separate tables below

0 (1)

1 (3)

0 (0)

2 (0)

1 (1)

0

VAP 5.37 (6.77)

< 15/1000 Ventilator

days Awaiting Awaiting SSI

(Breast-

6.2)

(VascularN

o data)

(0) < 4.9%

(Breast) < 9.9%

(Vascular) < 1.5% (Ortho)

CVC Associated Infections

8.53 (0)

0

(0)

0

(0.48)

7.75

(4.95)

< 10/1000 Catheter days (Haem/Onc)

< 3/1000 Catheter days

(All other areas)

Wd 1–96

Ward 8–No data

WARD 16-100

Ward 14 -

100

PVC Bundle

Wd 2–

91

Ward 9 – 87

Ward 17-

87

97

Ward 22-100

Ward 32 -

90

14 HDU –

100

> 95%



Ward 10 – 80

Wd18–No data

Ward 11 – 50

CIU - 100

Wd 3-100

Ward 12 - 91

Ward 19 - 60

Ward 34 - 60

Ward 42 - 86

Ward 22-100

Wd 32 – 100

CVC Maintenance Bundle

10 HDU – 95

96

RDU - 80 Wd 34 – 60

14 HDU –

100

> 95%

CVC Insertion Bundle

10 HDU – 100

94

14 HDU –

100

> 95%

NB: Previous Month’s Score in Brackets Awaiting, unable to collate data until end of month for May due to 30 day surveillance for SSI Antimicrobial Prescribing, white for Ward 20, Renal and Haem/Onc as no scores from November due to change in prescribing policy

Red

Amber

Green



Environmental Cleaning scores provisional as not received from Domestic services



Ward 40 Scorecard February 2009 March 2009

April 2009 May 2009



Hand Hygiene Results for Non-Scorecard Wards, Ninew ells Hospital May 2009

Ward 23a

Ward 23b

Ward 24

Ward 25

Ward 26

Ward 27

Ward 29

Ward 30

Ward 35

Ward 36

Ward 37

Ward 38

Ward 40

Ward 41

Hand Hygiene Complia

nce

No data (85)

No data (No

data)

90 (No

data)

100 (100)

No data (No

data)

100 (100)

90 (95)

No data (No

data)

No data (No

data)

80 (No

data)

No data (95)

100 (100)

No data (90)

No data (No

data)

Target for Hand Hygiene Compliance is > 95%



Scorecard Results as per Directorate, Perth Royal I nfirmary May 2009

Ward 1

Medical

Ward 5

Orthopaedics

Care of the Elderly

ITU

RDU

Target


65 (75)

95 (95)

95 (90)

90 (100)

90 (80)

100 (100)

100 (100)

> 95%

Awaiting


No data

(85)

No data

(86)

No data

(85) (100)

No data

(11)


NO

REPORT (No report)

> 95% (Orthopaedics –

Antibiotic Prophylaxis, All other areas –

Empirical Prescribing)

< 10% Care of Elderly

Sharps Injuries

0 (0)

1 (1)

0 (0)

0 (0)

1 (0)

0 (0)

0 (0)

0


0 (0)

0 (2)

0 (0)

0 (0)

0 (0)

0 (0)

0 (1)

0

Education 0 (0) 3 (3) 5 (5) 1 (1) 3 (3) 3 (4) 1 (1) > 4 Environmental Cleaning

100 (94)

100 (91)

100 (94)

100 (92)

100 (90)

100 (92)

100 (100)

> 90%


0 (2)

1 (3)

1 (0)

4 (1)

2 (2)

0 (0)

0 (0)

0


0 (0)

1 (2)

0 (0)

1 (0)

1 (4)

1 (0)

0 (0)

0



VAP < 15/1000 Ventilator days

Awaiting SSI (3.6)

< 1.5%


< 3/1000

Catheter days PVC Bundle NO DATA No data > 95% CVC Insertion Bundle

100

> 95%


70

60

> 95%

NB: Previous Month’s Score in Brackets Awaiting, unable to collate data until end of month for May due to 30 day surveillance for SSI Antimicrobial prescribing, white for ITU as no scores from November due to change in prescribing policy Environmental Cleaning scores provisional as not received from Domestic services

Red

Amber

Green



Scorecard Results as per Ward, Royal Victoria Hospi tal May 2009

Ward 1

Ward 2

Ward 3

Ward 4

Ward 5

Ward 6

Ward 7

Ward 8

Roxburghe East

Roxburghe

West

Target


95 (95)

100 (95)

100 (100)

No data (No

data)

95 (100)

100 (94)

90 (85)

85 (85)

95 (90)

95 (90)

> 95%


No data (100)

No data (100)

No data (100)

No data (100)

No data (100)

No data (100)

No data (100)

No data (100)

No data (100)

No data (100)

> 95%

Sharps Injuries

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0


0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

2 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0

Education 5 (4)

1 (2)

2 (2)

2 (2)

2 (2)

2 (2)

6 (6)

1 (1)

5 (5)

5 (5)

> 4

Environmental Cleaning

100 (99)

100 (98)

100 (97)

100 (91)

100 (98)

100 (95)

100 (93)

100 (93)

100 (94)

100 (97)

> 90%

Bed Occupancy

NOT AVAILAB

LE

NOT AVAILA

BLE

NOT AVAILA

BLE

NOT AVAILA

BLE

NOT AVAILA

BLE

NOT AVAILA

BLE

NOT AVAILA

BLE

NOT AVAILA

BLE

NOT AVAILABLE

NOT AVAILABLE

< 85%




0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (1)

0 (1)

0 (0)

0 (0)

0


0 (0)

0 (0)

0 (2)

2 (1)

0 (2)

0 (0)

0 (0)

1 (0)

0 (0)

0 (0)

0

VAP < 15/1000 Ventilator

days SSI < 1.5% PVC Bundle

No data 100 No data

> 95%

CVC Insertion Bundle

> 95%


> 95%

NB: Previous Month’s Score in Brackets Environmental Cleaning scores provisional as not received from Domestic services

Red

Amber

Green



Scorecard Results as per Ward, Stracathro Hospital May 2009

Ward 2

Ward 3

Surgical Unit

Stroke Unit

Target


100 (100)

No data (100)

95 (95)

90 (90)

> 95%


No data

(80)

No data

(80)


No data

(80)

> 95%

Sharps Injuries

0 (0) 0 (0) 0 (0) 0 (0) 0


0 (0)

0 (0)

0 (0)

0 (0)

0

Education 0 (0) 0 (0) 5 (4) 0 (0) 100% Environmental Cleaning

100 (100)

100 (100)

100 (100)

100 (100)

> 90%


0 (2)

0 (0)

0 (0)

0 (1)

0


0 (0)

0 (1)

0 (0)

0 (0)

0



VAP < 15/1000 Ventilator days

SSI < 1.5%


< 3/1000 Catheter

days NB: Previous Month’s Score in Brackets Environmental Cleaning scores provisional as not received from Domestic services Antimicrobial prescribing, white for Surgical Unit as no scores from November due to change in prescribing policy

Red

Amber

Green



Scorecard Results for Dundee, Angus and Perth & Kinross CHP May 2009

Angus

Perth & Kinross


96 (98)

90 (75)

Antimicrobial Prescribing NO DATA (100)

NO DATA (24)

Needlestick Injuries 0 (0)

0 (0)


0 (0)

0 (0)

Cleanliness Champions 3 (3)

< 2 (< 2)

Alert Conditions 100 (100)

100 (100)

New MRSA Acquisitions 1 (0)

1 (0)

New C. Diff Acquisitions 0 (0)

0 (1)

Environmental Audits Fed Back

> 95 (> 95)

> 95 (> 95)

NB: Previous Month’s Score in Brackets

Red

Amber

Green



Dundee CHP Scorecard May 2009

Carseview Ashludie Royal Dundee Liff Ward

1 Ward

2

LDAU

IPCU Ward

1 Ward

3 Ward

7 Ward

9 Ward

17 Ward

18 Ward

19 Ward

21 Ward

22 Ward

50 Hand Hygiene

Data Collection Not

Started

100

Data Collection Not

Started

100

100

(100)

100

(100)

Data Collection Not

Started

100

(100)

Data Collection Not Started



Sharps Injuries

0 (0)

0 (0)

0 (1)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)


0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

Education 2 1 23 1 1 1 3 2 0 1 1 2 3 2 Environmental Cleaning





0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)


0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

NB: Previous Month’s Score in Brackets



Targets for Angus and Perth & Kinross CHP Scorecard s

1. Hand Hygiene Compliance Audit of 20 staff as per Audit Tool . RED ≤ 94% GREEN ≥ 95% 2. Antimicrobial Prescribing . Compliance with empiric antibiotic policy: based on restricted antibiotic usage as a % of total usag e Perth & Kinross and Dundee Angus Restricted v Total Compliance with Empiric Policy (ARI)

RED ≥ 15% RED ≤ 49% AMBER 11 – 15% AMBER 50 - 94% GREEN ≤ 10% GREEN ≥ 95% 3. Needlestick Injuries identified via the AIM Syst em RED ≥ 2 AMBER 1 GREEN 0 4. HAI Bacteraemia RED ≥ 2 AMBER 1 – 2 GREEN 0 5. Education. Number of Cleanliness Champions on th e Ward per month RED ≤ 2 AMBER 3 GREEN ≥ 4 6. Alert Condition Organisms that are reported with in 24 hours to ICT/ the total amount identified RED ≥ 50% AMBER 99%-50% GREEN 100% 7. New Acquisitions of MRSA in hospitals RED ≥ 3 AMBER 2 – 3 GREEN 0 – 1 8. New Acquisitions of C.Difficile in hospitals RED ≥ 3 AMBER 2 – 3



GREEN 0 – 1 9. Environmental Audit Feedback. The number of audi ts fed back within the agreed timescale RED ≤ 50% AMBER 50%-94% GREEN ≥ 95%



APPENDIX 2: SGHD HAI Action Plan RAG Report (June R esponse) NHS BOARDS – NHS Tayside Response 15.06.09 Action: 2.1 All Boards will empower their Charge N urses to deliver against their responsibilities Lead: NHS Boards: Chief Executives Completion Date: October 2008 Status: COMPLETE Progress: In NHS Tayside the majority of our SCNs are Cleanliness Champions and there is a rolling programme to ensure that all SCNs complete the programme. NHS Tayside is implementing the job description recommended by Leading Better Care. All SCNs currently participate in environmental audits. Local Completion Date: December 2010 Comments/Outstanding Actions: Following review of environmental audit procedures a short life working group is being established to develop NHS Tayside standing operating procedures identifying roles and responsibilities of all staff Action: 2.2 Implement the recommendations in the S enior Charge Nurse Review Lead: NHS Boards: Chief Executives Completion Date: December 2010 Status: GREEN Progress: Both the Executive Team and Delivery Unit Committee support the full implementation of the revised SCN role. A programme board has been established with three supporting workstreams. An enabling organisation, role development and Quality and Patient Experience Learning Communities have been established to support all SCNs to develop the knowledge and skills required for the role. Learning Communities commenced November 2009. Local Completion Date: December 2010 Comments/Outstanding Actions: Action: 3.1 HAI SCRIBE (Healthcare Associated Infe ction System for Controlling Risk in the Built Environmen t) sections 3 &4 to be applied to all existing buildings to ensur e fabric of healthcare facilities maintained to minimise risk o f infection Lead: NHS Boards: Chief Executives Completion Date: August 2008 Status: COMPLETE Progress: HAI SCRIBE implemented in all refurbishment and maintenance projects in across NHS Tayside All NHST premises have been assessed for compliance with HAI SCRIBE. Local Completion Date: January 2009



Infection Control training has been given to Estates staff this will be revised to include use of HAI SCRIBE. Local Completion Date: November 2008. Revised to December 2008. Comments/Outstanding Actions: Training on the application of HAI SCRIBE required for Infection Control Nurses to support roll out of Estates training – Completed Local Completion Date: December 2008 A review of all community premises including application of HAI SCRIBE to existing premises will be completed by January 2009 - this is complete. Executive walkabouts to examine and address environmental issues have commenced. Ongoing programme of visits complete Local Completion Date: February 2009. Awareness raising and training planned for Capital Projects staff. This training has been carried out Action: 3.3 Planned preventative maintenance progr ammes reflect requirements of prevention and control of i nfection Lead: NHS Boards: Chief Executives Completion Date: October 2008 Status: COMPLETE Progress: Infection control is considered in all maintenance projects. System now in place to assess level of infection control input. Local Completion Date: November 2008 Comments/Outstanding Actions: Action: 4.1 NHS Boards to have ‘zero tolerance’ to non-compliance with hand hygiene Lead: NHS Boards: Chief Executives Completion Date: January 2009 Status: AMBER Progress: Hand hygiene audits undertaken in all clinical areas and are monitored by Infection Control. High risk areas are monitored using a Balanced Scorecard which highlights non-compliance as amber or red depending on result Hand hygiene policy reviewed and updated September 2008. All staff have access to this policy. Local Completion Date: March 2009. The bi-monthly reports being sent to the Board.



Comments/Outstanding Actions: Hand hygiene compliance and its importance to NHST to be included in all recruitment packs. Multidisciplinary group will look at implementation of this and dress code in March. Complete – Zero Tolerance approach incorporated in to Hand Hygiene policy. This polic y implemented in May 2009 awaiting ratification of Dr ess Code Policy. Action: 4.3 NHS Boards to report hand hygiene comp liance (staff and visitors) and facilities on a hospital b asis to 2 monthly Board meetings Lead: NHS Boards: Chief Executives Completion Date: January 2009 Status: COMPLETE Progress: 2 monthly reporting put in place immediately. Reports going to HAI Network bi-monthly (which is chaired by the CEO and feeds in to the Board), Executive Management Team, Tayside Improvement Panel and the Improvement and Quality Committee. Comments/Outstanding Actions: Public Partnership Group HAI members carrying out observations of visitors at selected ward entrances. These are planned for the whole of 2009. The results from these observations will be reported locally and to the Board. Action: 5.1 NHS Boards to ensure HAI budget requir ements are reflected in capital, maintenance and operational p rogrammes Lead: NHS Boards: Chief Executives Completion Date: April 2009 Status: AMBER Progress: Finance detail code in place for all infection control projects and maintenance programmes. This will give a benchmark for budgets in 2009/10. Comments/Outstanding Actions: Finance code has been in place 2008/09 awaiting confirmation of 2009/10 budgets. Action: 5.2 NHS Boards to have identified budget f or urgent repairs and replacement equipment available to Char ge Nurses Lead: NHS Boards: Chief Executives Completion Date: January 2009 Status: Red Progress: Current repairs are resourced through existing revenue budgets. Capital funding is available via a medical equipment group for prioritised equipment. HAI implementation fund supports environmental audit results, and compliance with timescales is monitored and audited through the Executive Team. Review of change demonstrated improvements can be made with Senior Charge Nurses holding budget for repairs. To be rolled out across NHS Tayside with Senior Charge Nurse review.



Comments/Outstanding Actions: To be actioned/discu ssed with General Manager once Management re-organisatio n completed September 2009 . Action: 6.1 All patients to receive information on HAI Lead: NHS Boards: Chief Executives Completion Date: November 2008 Status: COMPLETE Progress: An HAI leaflet developed with the PPG is available to all patients across NHST. Comments/Outstanding Actions: Action: 6.3 All information is available in a vari ety of formats that facilitates public understanding Lead: NHS Boards: Chief Executives Completion Date: November 2008 Status: COMPLETE Progress: Leaflets are available in plain English although we offer to provide translated versions on request. Hand hygiene visual messages at entrances to Ninewells and PRI providing information in several languages. HAI leaflets translated into top 5 languages within Tayside. Comments/Outstanding Actions: This will be evaluated as part of the PPG HAI Forum Work Plan Action: 7.1 NHS Boards to implements requirements of CEL 30(2008): Prudent Antimicrobial Prescribing: The Sc ottish Action Plan For Managing Antibiotic Resistance And Reducing Antibiotic Related Clostridium difficile Associated Disease. Lead: NHS Boards: Chief Executives Completion Date: August 2008 Status: COMPLETE Progress: All recommendations from CEL 30 (2008) are being fully implemented as below; • NHS Tayside has had an Antimicrobial Management Group

(AMG) set up for many years. It links with ADTC, HAI Network, ICM, Primary care CHPs as required.

• Regular reports on consumption of antibiotics are set up for key areas

• AMG reviews all SMC advice for antimicrobials before local implementation

• AMG monitors local resistance patterns and do not routinely report restricted agents on reports

• All GP practices have their seasonal variation of quinolones monitored 6 monthly as per HEAT target

• Restricted anti-microbial policy implemented in Secondary Care. • Monitoring of compliance set up for medical, surgical and care of



the elderly units throughout NHS Tayside. • Restricted policies for Community hospitals in place. • Restricted GP prescribing policy complete • Updated protocol for treatment of C difficile patients available to

primary and secondary care staff • Additional antimicrobial pharmacist started May 09 • Review of major surgical speciality prophylaxis regimes complete

in accordance with SIGN and SAPG guidance. • Education of independent sector pharmacists and nursing homes

arranged for June 09 Comments/Outstanding Actions: Local Completion Date: Action: 8.1 Scottish Patient Safety Programme (HAI elements) are integrated with HAI agenda at NHS Board level Lead: NHS Boards/Scottish Patient Safety Programme Completion Date: January 2009 Status : COMPLETE Progress: Working jointly on development and roll out of CVC, VAP and CAUTI bundles. Hand hygiene audits fully integrated. Complete. Comments/Outstanding Actions: Implementation plan for PVC and CVC bundle in progress. Compliance to be reported to performance management group, Clinical Governance etc. Action: 8.2 Progress on implementation of Scottish Patient Safety Programme (HAI elements) to be included in H AI reports to 2 monthly Board Safety Patient care bundles asso ciated with HAI Lead: NHS Boards Completion Date: January 2009 Status: COMPLETE Progress: hand hygiene included in Balanced Scorecard in high impact areas and reported to HAI Network bi-monthly, Executive Management Team, Tayside Improvement Panel and the Improvement and Quality Committee. Comments/Outstanding Actions: Action: 9.3.1 NHS Board’s infection control polici es include primary and community care Lead: NHS Boards: Chief Executives Completion Date: December 2008 Status: COMPLETE Progress: All local Infection Control policies apply to primary and community care. Complete. Comments/Outstanding Actions: Several policy sections under review. Local completion date December 2008.



Action: 10.1 Structure and resources to provide ef fective infection control service across NHS Board area (ho spital and community) assessed and agreed by NHS Boards, inclu ding:

• Human resources • Equipment • Budget

Lead: NHS Boards Completion Date: October 2008 Status: AMBER Progress: This has been an on-going process in Tayside. The Infection Control team was reviewed and redesigned in 2006/7 and is currently being looked at again. New money has been made available to support the Infection Control team. NHS Tayside is actively considering the considering the creation of a Directorate of Infection Prevention and Control. The final structure is yet to be agreed however the current structure remains in place with the Nurse Consultant (HAI) post in the process of b eing recruited to , and the Infection Control Manager Post being covered on a temporary basis by the Assistant Director of Nursing. Comments/Outstanding Actions: Initial draft of proposed restructure is currently out for consultation with key individuals. Infection control Manager’s post interviews to be h eld end of June 2009. Action: 11.2 NHS Boards policy/guidance on complet ing death certificates reviewed to include documenting death associated with HAI Lead: NHS Boards Completion Date: December 2008 Status: AMBER Progress: Awaiting guidance from either HPS or the SGHD to be in line with all areas in Scotland. New guidance has been issued from the Procurator Fiscal’s office and we have contacted them to seek clarification on some issues. Otherwise no specific instructions have been issued to staff over and above what is already required of them in death certification as regard causes with or without HAI. We would find it helpful is this was addressed at national level. A flow chart has been produced to help staff and is with Medical Director for review prior to discussion with the Procurator Fiscal and other Clinical staff. This is now with CLO and SGHD for comment. Local completion date: End of April 2009 Comments/Outstanding Actions: Informed by HAI Task Force that issue is currently with CMO. Further implement ation therefore on hold. Flow chart has been assessed by Legal Office



Action: 12.2 NHS Boards local surveillance to incl ude setting of control limits and trajectories for reduction of ra tes / incidence of HAI Lead: NHS Boards Completion Date: December 2008 Status: COMPLETE Progress: Complete. Comments/Outstanding Actions: Action: 13.1 NHS Boards Risk Register details HAI risks Lead: NHS Boards: Chief Executives Completion Date: September 2008 Status: COMPLETE Progress: HAI risks regularly reviewed and updated via SMART system. Comments/Outstanding Actions: The link between the corporate and operational risks is under review. Environmental audit results are kept on a risk register which is shared with the EMT on a monthly basis. Local Completion Date: End of October 2008. Action: 13.2 HAI incidents and issues recorded on NHS Boards Risk Register reporting systems and reported to 2 m onthly Board meetings Lead: NHS Boards: Chief Executives Completion Date: January 2009 Status: COMPLETE Progress: System in place to review all HAI recorded incidents and will be reported into Health and Safety Management Group and HAI Network from December 2008. Comments/Outstanding Actions: Action: 15.1 NHS Boards to self assess current com pliance with QIS HAI Standards (March 2008) Lead: NHS Boards: Chief Executives Completion Date: December 2008 Status: COMPLETE Progress: Any outstanding issues have been included in the Infection Control Annual Work Programme from which an exception report is submitted to the HAI Network. Complete. Comments/Outstanding Actions: This is now being rev iewed again to inform the 2009/10 programme of work. Action: 16.1 All healthcare workers receive approp riate level of HAI education and training in line with position, i ncluding antimicrobial prescribing and resistance Lead: NHS Boards: Chief Executives Completion Date: April 2009 Status: AMBER Progress: Included at all inductions-content being revised.



Local Completion Date: December 2008. Local education strategy developed and will be implemented from November. This includes a training matrix which details all available and levels of training for each staff group. Local managers will then agree training as part of the PDP process. Local Completion Date: November 2008. Complete with exception of antimicrobial prescribing - to be included in training by end of May 2009. Comments/Outstanding Actions: Education strategy de veloped and implemented, this now requires evaluation/impac t assessment. Action: 16.2 Infection Control staff undertake app ropriate level of education and training Lead: NHS Boards: Chief Executives Completion Date: April 2009 Status: COMPLETE Progress: All infection control staff have personal development plans which are guided by corporate HAI objectives. Complete. Comments/Outstanding Actions: Action: 19.2 Cleaning matrix and schedule includin g discipline responsible for cleaning is available in all health care settings Lead: NHS Boards: Chief Executives Completion Date: September 2008 Status: AMBER Progress: Domestic Services staff currently comply with national cleaning standards. The Lothian cleaning matrix has been adapted for local use and is currently being consulted on. Roll out is planned during November. Local Completion Date: November 2008. This matrix is complete and implemented across NHS Tayside. Comments/Outstanding Actions: Cleaning matrix imple mented but requires evaluation/review – completed, being m apped against new cleaning standards prior to launch. Action: 20.1 All staff to have HAI objective in an nual professional development plans Lead: NHS Boards: Chief Executives Completion Date: April 2009 Status: AMBER Progress: All nursing staff have HAI objectives. Comments/Outstanding Actions: this is being promoted and discussed at the launch of the HAI Education Strategy. Advice circulated to all managers. PDPs completed. A samp le of PDPs require review to ensure compliance. To be complete d august 2009.

nhs tayside infection control

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