Highland NHS Board

4 June 2013
Item 5.5(c)
INFECTION PREVENTION & CONTROL ANNUAL WORK PLAN (20132014)
Report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse
Director & Executive Lead, Infection Prevention & Control
The Board is asked to:

Note and Approve the Infection Prevention & Control Work Plan 20132014.

Background

NHS Quality Improvement Scotland (QIS) Healthcare Associated Infection (HAI) Standard 3b.3
requires Boards to develop an Annual Infection Prevention & Control Work Plan and Monitoring
Programme.
2

Annual Work Plan 2013 2014

During last year significant progress has been made with embedding the culture of Infection
Prevention & Control being Everyones Business. NHS Highland has low infection rates and, far
from being complacent, is aware that much work still needs to be done. This years Annual Work
Plan encompasses ten areas for action to prevent and control infection:1. HEAT Targets for Staphylococcus aureus and Clostridium difficile
2. Infection Prevention & Control Staffing resource
3. Infection Prevention & Control is everyones business
4. HAI Standards
5. HAI Education
6. Surgical Site Infections
7. Decontamination
8. Water Safety
9. Domestic Services
10. Catering Services
Information in respect of each area is contained in Appendix 1. The plan will be monitored by the
Infection Control Improvement Group. A detailed RAG rated action plan will be submitted quarterly
to the Control of Infection Committee and 6 monthly to the Board.
3

Contribution to Board Objectives

The Infection Prevention & Control Annual Work Plan supports NHS Highlands achievement of the
HEAT Target relating to infection control.
4

Governance Implications

By meeting the requirements of the Annual Work Plan, NHS Highland will continue to improve its
performance in respect of Staff, Patient/Public Involvement and Clinical Governance Standards
and fulfill, in part, the requirements of the Scottish Government Guidance.

Liz McClurg
Infection Control Manager
24 May 2013

APPENDIX 1

NHS Highland Infection Prevention & Control Annual Work Plan 2013/2014

Objective

Activity

Timescale

Lead Officer

a) By ensuring 95% compliance with device maintenance bundles

in Raigmore and the District General hospitals
PVC
CVC
Devise & implement PICC maintenance bundle
CAUTI

March 2014

Lead Nurses
Supported by the
Infection Prevention &
Control Team

March 2014

Infection Prevention &

Control Team

March 2014

Lead Nurses
Supported by the
Infection Prevention &
Control Team

1.HEAT Targets
1.1 To continue to reduce the number of SAB
cases to achieve the HEAT Target of 24 cases
per 100,000 acute occupied beds days or
lower by March 2015

b) Where applicable, roll out the use of maintenance bundles to all

other healthcare settings.
c) By raising awareness of and reinforce compliance with NHS
Highland wound management guidelines & formulary.
a) By reviewing the causes of community acquired SABs, to give
an understanding of what preventative measures are required.
b) By reviewing the causes of healthcare acquired SABs, to give
an understanding of what preventative measures are required.
1.2. To reduce the number of Clostridium
difficile cases to achieve the HEAT Target of
25 cases per 100,000 occupied bed days in
patients age 15 years and over by March
2015.

By monitoring the adherence to the Clostridium difficile policy to

highlight areas for improvement
a)hand hygiene compliance with remedial action if compliance is
less than 95%
b)Continue to improve empiric and prophylactic antimicrobial &
proton pump inhibitor prescribing

c)environmental cleanliness & fabric maintenance

d)appropriate isolation and monitor compliance
a)By ensuring the delivery of the most appropriate laboratory
testing

March 2014

Infection Prevention &

Control Team

March 2014

Infection Control
Manager
Supported by Lead
Nurses.

March 2014

Consultant
Microbiologist, Strategic
Lead for Infection
Prevention.

b)By ensuring that up-to-date infection rates are widely

disseminated

2. Infection Prevention & Control

Staffing resource
2.1 To initiate Infection Prevention & Control
service project plan to look at what resource is
required to ensure that all disciplines of staff
across Highland have access to specialist
infection prevention & control advice and
guidance.

a) By identifying current resources within the IP&CT.

b) By reviewing where infection prevention & control input is
required in each operational unit, exploring how this can be
delivered.
c) By reviewing the structure of the IPC service to ensure effective
teamwork.
d) By reviewing the role of the Infection Prevention & Control
Nurse ensuring time is built into job plans for education & training.
e) By reviewing the role of the IP&C Link Nurse Practitioner

2.2 To review the use of Infection Prevention &

Control Doctor resource and agree a model of
sustainable provision with the Operational
Units.

a) By identifying where infection prevention & control input is

required in each operational unit, exploring how this can be
delivered.

3. Infection Prevention & Control is

everyones business
3.1 Embed the importance of Infection
Prevention & Control into everyday practice.

a) By undertaking the rolling programme of Standard Infection

Control Precautions compliance monitoring.

March 2014

Lead Nurses
Supported by the
Infection Prevention &
Control Team

March 2014

Lead Nurses
Supported by the
Infection Prevention &
Control Team

March 2014

Lead Nurses
Supported by the
Infection Prevention &
Control Team

b) By ensuring that there is Infection Prevention & Control input in

all new builds/refurbishments as per HAI Scribe.
c) By ensuring that there is Infection Prevention & Control input in
procurement of reusable equipment
d) By identifying and reporting non- compliant sinks & poor fabric
condition.
e) By auditing compliance with NHS Scotland MRSA Screening
policy.

4.HAI Standards
4.1 Embed the process and governance
arrangements for HAI Standards Monitoring.

a) By ensuring there is a programme of HAI standards monitoring

visits in each Operational Unit.
b) By ensuring that there is a system in place to escalate any
actions which cannot be progressed through the line management
structure and if necessary to the Chief Operating Officer.
c) By submitting quarterly reports to the Infection Control
Improvement Group.

5.HAI Education
5.1 Through the HAI Education Group:To ensure Patient/Service Users safety is
achieved in relation to Infection Prevention &
Control by standardising HAI education and
training, targeted at different staff groups

a) By implementing the recommendations of the HAI Education

Group
b) By addressing the barriers preventing HAI training

across NHS Highland in

Hospitals
Community
Primary Care
Care Homes
Care at Home
Adult Day Care Centres
Learning Disability
Bank Staff
Social Work Staff
Volunteers and Contractors

c) By ensuring that there is a robust system of recording of what

training has been undertaken

6.Surgical Site Infections

6.1. To reduce elective colorectal surgical site
infections to 10% for 6 consecutive months

By the development and adherence to the Colorectal infection

reduction action plan

March 2014

6.2. To maintain in year rate of <5% for

elective and emergency Caesarean Section
Surgical Site Infections

By maintaining adherence of current practice.

March 2014

6.3. To maintain Orthopaedic Surgical Site

Infections at <1% by March 2014.

By continuing the present process of RCA of infections,

surveillance and feedback

March 2014

6.4 Comply with all HPS mandatory

surveillance

a) By reviewing the resource required.

March 2014

b) By setting up systems and processes to enable the collection of

SSI data.
c) To further the rollout of the ICNet electronic surveillance system
to include Argyll & Bute CHP and with the addition of the
admission, discharge and transfer tracking programme.

Colorectal Team
Supported by the
Infection Prevention &
Control Team
Obstetric & Midwifery
Teams
Supported by the
Infection Prevention &
Control Team
Orthopaedic Team
Supported by the
Infection Prevention &
Control Team
Infection Control
Manager
Supported by the
Infection Prevention &
Control Team

7.Decontamination
7.1 Improve compliance with all aspects of
decontamination.

a) By ensuring that there are systems, processes and facilities for

safe endoscopy decontamination.

March 2014

NHS Highland
Decontamination Group

March 2014

Lead Nurses
Supported by the
Infection Prevention &
Control Team

March 2014

NHS Highland
Professional Lead for
Soft Facilities Services

a) By putting systems in place around procurement of equipment

to ensure effective decontamination.
b) By ensuring that there are systems, processes and facilities for
safe decontamination.
c) By ensuring that there are plans in place for all (General Dental
Practitioners) GDP independent contractors to be able to provide
LDU facilities within their practices for the decontamination of
instruments which are compliant with SHPN 13 Part 2.

8.Water Safety
8.1 Through the Water Safety Group, ensure
NHS Highland has robust and consistent
arrangements in place for the safety of the
water systems in NHS Highland comply with
legal duties and relevant guidance

a) By implementing procedures for the prevention of water-borne

infection which include risk assessment, analysis and planned
preventative maintenance.
b) By ensuring that daily water flushing is carried out to reduce the
risk of water borne infection in accordance with the SOP.

9.Domestic Services
9.1 To support Domestic Services to achieve
90% Cleaning compliance.

a) By the development and implementation of Standard Operating

Procedures (SOPs), including products used and reports to Senior
Charge Nurses
b) By the development and implementation of Domestic Services
SOPs Training
c) By the development and implementation of Domestic Services
Standard Monitoring Procedures and Monitoring Training.

d) By assessing Domestic Services staffing levels based on the

agreed SOPs.
e) By monitoring the implementation of COSHH procedures &
Risk Assessments.

10. Catering Services

10.1 To support Catering Services & Clinical
Staff to ensure food safety from production to
delivery.

a) Through education & training such as

Elementary Food Hygiene Certificate
Hazard Analysis and Critical Control Points
(HACCP) Training
Food Service at Ward Level
b) By monitoring compliance with food safety standards.

March 2014

NHS Highland
Professional Lead for
Soft Facilities Services