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					                                                                          Highland NHS Board
                                                                                   1 May 2007
                                                                                      Item 7.6


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
       7. Immunisation
       8. Policy Reviews
       9. Pandemic Flu
       10. Education
       11. Audit
       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


     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

2. Corporate
   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

Corporate Objectives
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.
3. Quality
   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
                                                             Infection Committee.

4. Monitoring
   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.
                      Outbreak Surveillance
                                                        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
                                                                      Clostridium difficile
                                                                      VRE                                            GREEN
                                                                      ESBLs

                                                        And „alert conditions‟ i.e.
                                                                     Tuberculosis
                                                                     Meningitis

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
                                                            care pathway.

                       b) Appoint MLSO and MLA              Implemented.                                               GREEN

                       c) Appoint Infection Control Nurse   Implemented.                                               GREEN

                       d) Appoint Antimicrobial             Recruitment of this post now underway.
                          Pharmacist                                                                                   AMBER

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.

7. Immunisation
                  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
                         Encephalopathies (TSE)
                    g)   Control of Viral Haemorrhagic
                         Fevers (VHF)
                    h)   Legionella
                    i)   Antibiotic
                    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.

10. Education
                     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
                        infection control.

11. Audit
                     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

Audit cont…..
                                                               In addition to the above, local audits have been
                                                               conducted in various hospitals in NHS Highland and           AMBER
                                                                   Environment
                                                                   Management of Patient Equipment
                                                                   Waste Disposal
                                                                   Disinfectants & Antiseptics
                                                                   Clinical Practices
                                                                   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
                                                               Audit Programmes.

                        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
                          Development Fund.

14. Scottish
    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


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