Highland NHS Board
1 May 2007
INFECTION CONTROL ANNUAL WORK PLAN 2006/07) – PROGRESS REPORT
Report by Morag A Greenshields, Infection Control Manager for Heidi May, Executive
Lead, Infection Control
The Board is asked to:
Note the Progress Report in respect of the Infection Control Annual Work Plan 2006 –
Note that a revised Infection Control Annual Work Plan (2007 – 2008) will be
submitted to the August Board Meeting.
1. Background and Summary
In 2003 the Chief Medical Officer identified the prevention and control of Hospital Acquired
Infection (HAI) as a high profile priority issue for NHS Scotland. This resulted in the
development of the NHS Scotland Code of Practice for the Management of Hygiene and
HAI. With effect from May 2004 all NHS Boards were instructed through SEHD / CMO
(2004) 9 to implement the Code of Practice with immediate effect.
Section 7 of the Code of Practice - Compliance Management, requires Boards to develop an
annual infection control and monitoring programme. This should include audit activity and
seek to identify areas of deficiency. From the findings, a local Action Plan must be initiated.
The purpose of this report is to provide an update in terms of compliance with the different
activities detailed in the 2006 -2007 work plan and identify areas where further work is
2. The Annual Work Plan 2006 – 2007
A total of fifteen activity areas were identified for inclusion in the Infection Control Work Plan
(2006 – 07). These include:-
1. The Local Delivery Plan
2. Corporate Objectives
3. Quality Improvement Scotland (QIS)
4. Monitoring HAI
5. Invest HAI Implementation & Development Fund Effectively
6. Decontamination & Sterilization
8. Policy Reviews
9. Pandemic Flu
12. Advice & Support
13. Development of Infection Control Service for NHS Highland
14. Scottish Executive Policy
15. Clinical Governance & Risk Management
Detailed information in respect of each activity is contained in Appendix 1. The compliance
rate is identified using the RAG format i.e. Red = 0 - 70%; Amber 70 - 90%, Green 90 -100%.
Working with you to make Highland the healthy place to be
3. Contribution to Corporate Objectives
The HAI Annual Work Plan progress report supports NHS Highland‟s achievement of the
HEAT Target relating to infection control.
4. Governance Implications
By meeting the requirements of 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 Executive Guidance detailed
a) The NHS Scotland Code of Practice for the Local Management of HAI – CMO (2004) 09
b) Infection Control and Cleaning: Nursing Issues – HDL (2005) 7
c) Infection Control: Organisational Issues HDL (2005) 8
d) Quality Improvement Scotland Standards – Healthcare Associated Infection (Infection
e) HAI Task Force Delivery Plan 2006 – 2008
f) Decontamination – Updated Guidance on Compliance in Primary Care – HDL (2006) 40
5. Impact Assessment
As Infection Control policies are updated they will be impact assessed for equality and
Morag A Greenshields
Infection Control Manager
20 April 2007
NHS HIGHLAND INFECTION CONTROL ANNUAL WORK PLAN 2006 - 2007
SUBJECT OBJECTIVE ACTIONS PERFORMANCE
1. Local Delivery
Plan a) Reduce the rate of blood borne Since January 2003, NHS Highland is one of only 9
MRSA Infections acute divisions showing quarterly rates of MRSA
bacteraemia consistently within the expected range. Our
rates are below the Scottish average, and similar to rates
of other Scottish divisions of comparable size and GREEN
complexity. In three of the last six reported quarters,
NHS Highland achieved the Board‟s corporate objective
in reducing the number of bacteraemias to below 0.08
per 1000 acute occupied bed days, with our rate below
our average of 0.11 in five of the last six reported
quarters. Overall, the number of MRSA bacteraemias
has reduced from 22 in 2005 to 13 in 2006.
b) Increase the uptake of MMR MMR uptake across NHS Highland has increased
Vaccine steadily throughout the last year. The latest quarterly
uptake rate, during October – December 2006, among AMBER
children aged 2 years old was 89.5%. This was the
highest level seen for several years and has risen from
the previous 3 quarter levels of 77.9%, 85.5% and 87.1%
respectively throughout the last year. This compares to
the national target of 95%. Now that public and
professional confidence in MMR safety has returned we
anticipate seeing further increases in uptake levels next
Objectives a) Maintain the low level of post In-patient Surgical Site Inspection rates for SSU, North,
operative surgical site infections Mid, and SE Highland CHPs for 2006 are: post hip
replacement, 0.5%; knee replacement, 0.7%; fracture GREEN
neck of femur, 0.7%; major vascular surgery 5.1%;
abdominal hysterectomy 1.5%; caesarean section 1.2%.
These rates compare favourably with both NHS Scotland
and Pan-Celtic rates. In addition, NHS Highland has also
achieved the Board‟s corporate objective of maintaining
the level for post-operative surgical site infections after
hip and knee replacements to less than 1%.
There are no surgical procedures in the surveillance
category undertaken in Argyll.
b) Ensure each ward and To date, a total of 82% of wards and clinical areas within
department has a named SSU, North, Mid, and SE Highland CHPs have a named
Cleanliness Champion Cleanliness Champion (CC). 76% have a CC who is a
charge nurse or deputy. This achievement has been AMBER
facilitated by the appointment of two CC facilitators from
November 06 to March 07.
15 staff have completed the course in Argyll & Bute.
28 staff in Argyll & Bute are currently undertaking the
c) Ensure appropriate widespread Alcohol gel and liquid soap are widely available
availability of hand hygiene throughout NHS Highland. GREEN
cont. d) Undertake structured cleanliness A rolling programme of structured cleanliness surveys
surveys of clinical areas with throughout NHS Highland is being carried out by, or
Patient Council representatives. under the supervision of, the Hotel Services Manager.
Patient Council representatives are included where AMBER
appropriate. The results of the surveys are being
monitored by the HAI Working Group.
Further work to be undertaken to extend patient
representation to all hospitals.
The Nurse Board Director and Head of Facilities have
commenced a programme of personal ward cleanliness
spot checks pan Highland.
Improvement a) Review compliance with the 69 Considerable work had been done in this area and NHS
Scotland HAI standards and work towards Highland, pre 2006, was judged to have met 64 of the 69
full compliance. standards which makes NHS Highland 92 % compliant. GREEN
Further works are ongoing and outstanding standards
are being well progressed.
Monitoring is through the NHS Highland Control of
Healthcare a) Continue participation in national Full details on these activities for NHS Highland are
Acquired surveillance schemes, to reported as per the Scottish Executive requirements.
Infection Scottish executive and HPS Post-discharge surveillance for SSI after caesarean
requirements including:- section, surveillance for Clostridium difficille associated
MRSA bacteraemia disease (CDAD) and Staph aureus bacteraemia
Surgical Site Infection surveillance have commenced according to HPS
Argyll & Bute are participating in post transfer and post
discharge surveillance of elective knee, hip and
caesarian sections of patients undergoing surgery in
Royal Alexandria or Inverclyde Hospitals, led by NHS
Glasgow & Clyde and are compliant.
Full compliance achieved pan Highland.
National HAI prevalence
survey. NHS Highland has participated in the national HAI
prevalence survey and the report is awaited.
b) Maintain “Alert Organism” Ongoing surveillance of „alert organisms‟ i.e.
surveillance programme. MRSA
And „alert conditions‟ i.e.
5. Invest HAI
Implementation a) Implement Fast Track MRSA Because new technologies for molecular screening of
and Development PCR MRSA are currently being evaluated, it has been agreed
Fund Effectively to revisit this in the future rather than invest in old
technology. The monies have been re-directed to
purchase additional laboratory consumables for
conventional screening for MRSA, and for printing MRSA
b) Appoint MLSO and MLA Implemented. GREEN
c) Appoint Infection Control Nurse Implemented. GREEN
d) Appoint Antimicrobial Recruitment of this post now underway.
6. Decontamination a) Support and monitor progress The Sterile Services Department at Raigmore Hospital is
and Sterilization towards ensuring that fully compliant with the requirements of the Glennie
sterilization and disinfection Report and is registered with the MRHA. Regular audits
facilities comply with existing are undertaken by BSI.
guidance, including compliance GREEN
with the Glennie Report. Within SSU, decontamination and sterilization facilities
and practices meet, or are on schedule to meet, existing
guidance. The one exception is dental / orthodontics,
which is being considered alongside dental units (see
Decontamination & b) Support and monitor progress New endoscope reprocessors have been installed and
Sterilization cont…. towards ensuring improved commissioned throughout SSU, North, Mid, and SE
endoscope decontamination Highland CHPs, and are fully operational. Rinse water
facilities. testing is being undertaken in Microbiology according to
HIS Guidance. Snagging issues have been identified,
particularly with the Wassenburg (Dawmed) machines.
Corrective action is in place. The facilities in some of the
peripheral clinics (apart from the washer-disinfectors) are
working towards full compliance. AMBER
Oban – plans are progressing to replace the Aphos
EWDs with Sterilox Endoscopic Decontamination System
Dunoon – plans are progressing to replace the Aphos
EWDs with Wassenberg EWDs
A monitoring officer/trainer has been funded to carry out
annual inspections of sites to ensure compliance with
current best practice.
c) Assess compliance with Glennie Audits of all primary care decontamination sites are now
Group Technical Requirements 44% complete. Funds to enable the necessary work
in primary Care Settings (PCAT). have been estimated and identified through the Asset AMBER
Management Group. The HPS deadlines have been
renegotiated to the end of May 2007.
a) Oversee the work of Highland HICOG has met 4 times over the past year and
Immunisation Co-ordinating successfully overseen the implementation of the new
Group (HICOG) national childhood vaccination programme.
Pneumococcal vaccination has been introduced to the
routine infant immunisation programme as well as a GREEN
booster for Hib and Men C. Training on the new vaccines
for local health professionals was delivered and call
recall systems amended to incorporate the new vaccines.
A great deal of work has been done in primary care to
accommodate the additional appointments required. The
first uptake levels from the new vaccines are expected in
the early summer.
b) Co-ordinate implementation of As per 1 above.
new national Childhood
vaccination Programme. GREEN
c) Develop new TB “High Risk” The schools BCG programme has now ceased across
prevalence service to replace the UK. Alternative arrangements have been agreed for
the school based BCG high risk persons locally. Some Health Visitors have
programme. been trained within each CHP area to give Mantoux tests
and BCG vaccination. A postal questionnaire has been
completed by all parents of children in P1-S2 in Highland
and Argyll schools. All “high risk” children have been AMBER
identified and are now being offered follow up and testing
as appropriate. Nurse led clinics are underway in the
North and mid CHPs. Work is still ongoing in SE CHP
with regard to service redelivery. Argyll & Bute CHP are
using community paediatricians to see these children. In
addition, a postnatal testing service has been established
for young infants.
Immunisation d) Develop a Mass Vaccination A draft mass vaccination plan has been established for
cont….. Plan for the local population. Highland Council area. Work is still ongoing to develop
robust staffing arrangements for the numerous AMBER
vaccination centres that would be required to deliver
whole population vaccine coverage over a 3 day period.
A clear way forward has now been agreed for the Argyll
& Bute area.
8. Policy Reviews
a) Standard Infection Control All policy reviews completed.
b) Hand Hygiene
c) Decontamination The Standard Infection Control Policy is now redundant
d) MRSA and has been withdrawn.
e) Outbreak GREEN
f) Transmissable Spongiform
g) Control of Viral Haemorrhagic
j) Tuberculosis (TB)
9. Pandemic Flu
a) Develop and exercise an NHS A Highland pandemic flu contingency plan has been
Contingency Plan for Pandemic developed and agreed. It is about to undergo its 3rd
Influenza. update and revision in accordance with new versions of
national planning documents. It has been submitted to a
“QIS” type review by Health Protection Scotland and final GREEN
feedback is awaited on that review. NHS Highland reps
participated in a UK wide pandemic flu exercise through
the Highlands & Islands Strategic Coordinating Group.
Two NHS corporate strategic table top exercises have
been held on pandemic flu and several more local CHP
based training events and presentations have taken
Pandemic Flu cont… b) Develop a management plan for Contingency plans and guidance have been developed
protecting human health in the nationally for human cases of avian influenza. These
event of an outbreak of avian flu cover the public health and clinical aspects of treatment GREEN
in birds. and care and can be utilised locally if required. They are
available on the HPS website.
a) Support and roll out education Between March 06 and February 07, the ICT conducted
programmes including: in excess of 130 education sessions reaching over 1700
members of staff, a significant increase on the previous GREEN
Link Nurse training year. Link Nurse Training is scheduled for May / June
Cleanliness Champions Please refer to item 2 (b) AMBER
b) Support re-introduction of Mandatory induction training in infection control has been
mandatory induction training in successfully re-introduced pan Highland. GREEN
a) Develop, support and monitor The Audit Programme included five audits: Hand
progress of NHS Highland Hygiene Compliance; Laundry; Food Hygiene & Pest
infection control audit Control; Use of Personal Protective Equipment; Safe use AMBER
programme. of sharps and disposal of sharps. These were conducted
in a number of hospitals throughout Highland. Of the five
Audits, three have been completed and two are in
In addition to the above, local audits have been
conducted in various hospitals in NHS Highland and AMBER
Management of Patient Equipment
Disinfectants & Antiseptics
Cleanliness of Commodes and Toilets
Difficulties have been experienced in the preparation of
reports. This is as a result of staff shortages in the
Infection Control Team, particularly out with Raigmore.
12. Advice and a) Provide on-going advice and
Support support Achieved and on going.
During Critical incidents and
To Incident Control Team.
13. Development of
Infection Control a) Fully integrate Argyll & Bute Governance arrangements negotiated with Argyll &
Service for NHS Infection Control Services, Clyde for Argyll & Bute services and in place. Argyll &
Highland procedures and structures Clyde Lead Infection Control Doctor accountable for
including work of audit Argyll & Bute services via NHS Highland Medical AMBER
programmes. Director. Work is underway to integrate Argyll & Bute into
NHS Highland Infection Control Management Structure.
Integration of Argyll & Bute staff into NHS Highland
Committee Structure completed. Work under way to align
b) Appoint an Infection Control Implemented GREEN
Development of c) Monitor resourcing of Infection The ICT is adequately resourced to meet current service
Infection Control Control in NHS Highland, taking demands. However, staffing absence, particularly in the
Service for NHS account of proposed service North and Mid-Highland CHPs due to long term sickness
Highland cont….. developments, to ensure that it absence and secondment, make this challenging. In AMBER
is adequate to meet demand. order for the ICT to meet demands, it is vital that the ICN
post funded by the HAI Implementation and Development
fund continue post March 2008. This is to be addressed
with the Scottish Executive.
d) Monitor spend of HAI HAI Fund delegated in full to Lead Infection Control
Implementation and Clinician and accounted for. GREEN
Executive Policy a) Respond to and co-ordinate CNO (2006) 1 National Hand Hygiene Campaign for
local implementation of any new Scotland – The campaign was launched in January 2007.
national policy and guidance. A range of activities including Hand Hygiene Audits and GREEN
staff, patient and public awareness sessions will be
implemented throughout the year.
Scottish Executive policy requires all orthopaedic units to
have changed over to using pre-packed, sterile, single-
use implants by 31st December 2007 (HDL(2007)4). The AMBER
financial and storage impact of this is currently being
Scottish Executive HDL (2006) 38 Human Resource Policy for Staff
Policy cont…… Screening During Incidents and Outbreaks. Policy GREEN
15. Report to the
Risk Management a) Prepare Annual Report Achieved and ongoing.
and Clinical GREEN
Committee and b) Copies of Minutes
as appropriate to Achieved and ongoing. GREEN
the NHS Board