NHS Board Meeting 16Th October 2012 Board Medical Director

NHS Board Meeting 16th October 2012

Board Medical Director Board Paper No. 12/42

Healthcare Associated Infection Reporting Template (HAIRT)

Recommendation:

The NHS Board is asked to note the latest 2 monthly report on HAI within NHSGGC

INTRODUCTION

The attached HAI report is the latest of the regular two monthly reports to NHS Board as required by the National HAI Task Force Action Plan. The report presents data on the performance of NHSGGC on a range of key HAI indicators at National and individual hospital site level.

This is a revised template as specified by the Scottish Government.

Author’s name Dr Jennifer Armstrong Title Board Medical Director Contact tel. No. 64407

Healthcare Associated Infection Reporting Template (HAIRT) Section 1 – Board Wide Issues

This section of the HAIRT covers Board wide infection prevention and control activity and actions. For reports on individual hospitals, please refer to the ‘Healthcare Associated Infection Report Cards’ in Section 2.

A report card summarising Board wide statistics can be found at the end of section 1

NHS Greater Glasgow & Clyde Key Healthcare Associated Infection Headlines for October 2012 This is the thirteenth publication of the revised reporting template for submission to the NHS Board as required by the national HAI Action Plan. Appendix 1 contains Statistical Process Control Charts (SPC) for eight of the Acute Hospitals within NHSGGC. These contain data on Hospital Acquired Meticillin Resistant Staphylococcus aureus (MRSA) & Clostridium difficile infections at hospital level. An explanatory text on how to interpret SPCs is also included.

• In 2007 the Scottish Government Health Directorates issued a Local Delivery Plan (LDP) HEAT target in relation to Staphylococcus aureus Bacteraemia (SABs) in which NHSGGC successfully reduced SABs by 35% by April 2010. This target was extended by an additional 15% reduction which was also successfully achieved by 31st March 2011. For the last available reporting quarter (April – June 2012) NHSGGC reported 0.312 cases per 1000 AOBDs, NHS Scotland reported 0.302 per 1000 AOBDs. The revised National HEAT target requires all Boards in Scotland to achieve a rate of 0.26 cases per 1000 acute occupied bed days (AOBDs) or lower by 31st March 2013. Subsequent HAIRT reports will update on our progress towards this challenging target.

• The National Report published in October 2012 (April – June 2012) shows the rate of C. difficile within NHSGGC as 0.25 per 1000 occupied bed days in over 65s and clearly places the Board below the national mean (0.31 per 1000 OBDs in over 65s) and also below the revised HEAT target, in patients aged 65 & over, to be attained by the 31st March 2013 of 0.39 cases per 1000 total occupied bed days. Subsequent HAIRT reports will update on our progress towards this target.

• SSI Rates for all procedure categories apart from reduction of long bone fracture remain below the national average.

• Cleanliness Champions Programme - The Cleanliness Champions Programme is part of the Scottish Government's Action Plan to combat Healthcare Associated Infection (HAI) within NHS Scotland. To date NHSGGC have supported 2767 members of staff who are now registered Cleanliness Champions. Staphylococcus aureus (including MRSA)

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at:

Staphylococcus aureus : http://www.nhsinform.co.uk/Health-Library/Articles/S/staphylococcal- infections/introduction

MRSA: http://www.nhsinform.co.uk/Health-Library/Articles/M/mrsa/introduction NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

NHSGGC MRSA Screening Project

On 23rd February 2011, the Scottish Government announced new National minimum MRSA Screening recommendations. Targeted MRSA screening by specialty (implemented in Jan 2010) has now been replaced by universal clinical risk assessment (CRA) followed by a nose and perineal screen (if the patient answers yes to any of the questions within the CRA.). NHSGG&C met the deadline for implementation of the new programme by March 31st 2012 and await SGHD guidance on the introduction of Key Performance Indicators to measure compliance with the screening programme. These will be implemented in this financial year and will be reported nationally next year.

SAB HEAT Target 2013 Interventions

Infection Control enhanced surveillance methodology and reports in relation to MRSA/MSSA bacteraemia are being reviewed routinely in order to provide directorates with accurate information with regards to where and why these types of infections are occurring. The directorate reports utilise improvement methodology such as Pareto and run charts to allow directorates to target and plan areas for intervention. Multi disciplinary cross directorate representatives review this information and plan strategies to prevent avoidable infections locally.

Whilst the primary interventions were based in acute and this will continue, there is now a focused piece of work being progressed to investigate community onset HAIs (COHAI). It is hoped that targeted intervention in this area will reduce the incidence of MRSA/MSSA bacteraemia further.

Please note that the data presented in the following report cards are for Staphylococcus aureus bacteraemia infections only.

Clostridium difficile

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: http://www.nhsinform.co.uk/Health-Library/Articles/C/clostridium-difficile/introduction NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/clostridiumdifficile.aspx?subjectid=79

The National Report published in October 2012 (April – June 2012) shows the rate of C. difficile within NHSGGC as 0.25 per 1000 occupied bed days in over 65s and clearly places the Board below the national mean (0.31 per 1000 OBDs in over 65s) and also below the revised HEAT target, to be attained by the 31st March 2013 of 0.39 cases per 1000 total occupied bed days.

Infection Control Teams in NHSGGC complete the Health Protection Scotland Trigger Tool if there are two or more linked HAI cases of CDI in any clinical area in a two week period. Part of this process includes the referral to the Antimicrobial Management Team who will review the use of antibiotics within the area.

Hand Hygiene

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: http://www.washyourhandsofthem.com/ NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national hand hygiene monitoring can be found at: http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

NHSGGC has demonstrated a steady rise in Hand Hygiene compliance during the National Audit periods from a 62% baseline in February 2007 to achieve the 90% target in September 2008 and a current figure of 96% (LHBC Audits) reported in the September 2012 HPS report.

Hand Hygiene Compliance audits are carried out on a monthly basis in the majority of wards and departments in NHSGGC and these results populate the HAIRT. This information is used at local level to tackle issues that may affect staff practice. Results are fed back through Directorate based reporting mechanisms which allows management to view the progress of individual wards.

The audit process has been revised to reflect Combined Compliance, as well as opportunities taken. Combined compliance involves taking the opportunity and completing Hand Hygiene to a required standard. If this does not occur then the overall score awarded is a failure. Elements of these criteria include being bare below the elbows and following a six step technique that covers all areas of staff hands.

Cleaning and the Healthcare Environment

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

All areas within NHSGGC scored green (>90%) in the most recent report on the National Cleaning Specification. It should be noted that a new recording format has been in use since April 2012 and data has been combined for Victoria Infirmary & New Victoria Hospital for the Victoria Infirmary report card, date combined for Gartnavel General, Beatson Oncology & Homeopathic Hospital for the Gartnavel General report card and data also combined for Southern General, Langlands Unit & the New South Glasgow Hospital for the Southern General Hospital report card.

Outbreaks/Exceptions

Norovirus

Three hospitals and five wards reported Norovirus activity in September 2012.

Jul-12 Oct-11 Apr-12 Apr-12 Jan-12 Jan-12 Jun-12 Jun-12 Mar-12 Feb-12 Nov-11 Nov-11 Dec-11 Sep-12 Aug-12 Aug-12 Month May-12 Ward Closures (Norovirus) 1 2 11 10 13 14 10 26 5 1 0 5

Data on the numbers of wards closed due to confirmed or suspected norovirus is available from HPS on a weekly basis. http://www.hps.scot.nhs.uk/haiic/ic/noroviruspointprev.aspx

Other HAI Related Activity Surgical Site Infection (SSI) Surveillance NHSGGC participates in the Surgical Site Infection (SSI) surveillance programme that is mandatory in all NHS boards in Scotland. All NHS boards are required to undertake surveillance for hip arthroplasty and caesarean section procedures as per the mandatory requirements of HDL (2006) 38 and CEL (11) 2009.

Readmission surveillance is carried out using prospective readmission data on all 4 Orthopaedic procedure categories under inpatient surveillance up to 30 days post operatively.

Post discharge surveillance until day 10 post operation is also carried out for all caesarean sections performed, with the assistance of our Community Midwifery colleagues.

Last available quarter (January – March 2012) SSI Rates for all procedure categories apart from reduction of long bone fracture remain below the national average.

NHSGGC National dataset Category of procedure Operations Infections SSI rate (%) SSI rate (%)

Caesarean section 1240 12 1.0 2.1

Hip arthroplasty 512 3 0.6 0.8

Knee arthroplasty 551 0 0.0 0.1

Reduction of long bone fracture 231 1 0.4 0.3

Repair of neck of femur 201 1 0.5 0.8

The SSI rates for Caesarean section (inpatient and PDS to day 10), Hip arthroplasty (inpatient and readmission to day 30), Knee arthroplasty (inpatient), Reduction of long bone fracture (inpatient) and Repair of neck of femur (inpatient) procedures within NHS Greater Glasgow & Clyde, 01/01/2012 - 31/03/2012.

NHS Greater Glasgow & Clyde Total Staphylococcus aureus Bacteraemia Cases (all ages)

Data presented for Clostridium difficile Infection cases in ages 15 & over, 70

Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia cases & 60 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases.HEAT 50 target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene Compliance- monthly compliance across NHSGGC greater than 40 96%. 30 Cleaning Compliance -monthly compliance across NHSGGC greater than 94%. 20 Estates Monitoring -monthly compliance across NHSGGC greater than 93%. 10

N.B. New Domestic & Estates monitoring compliance format introduced by 0 Health Facilities Scotland in April 2012. Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 36 33 44 33 39 31 34 42 42 31 35 34 S e p - 11 O c t - 11 N o v - 11Hand D e c - 11 Hygiene J a n - 12 F e bMonitoring - 12 M a r - 12 A pCompliance r - 12 M a y - 12 J u(%) n - 12 J u l - 12 A u g - 12 97 97 96 98 97 98 97 97 97 97 98 98 MRSA Bacteraemia Cases (all ages) 70

50 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n -Cleaning 12 F e b - 12 Compliance M a r - 12 A p r - 12 (%) M a y - 12 J u n - 12 J u l - 12 A u g - 12 94.9 94.9 94.8 94.6 95.5 94.5 94.7 95.4 94.9 94.7 94.7 95 40 30

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12 (%) J u n - 12 J u l - 12 A u g - 12 0 93.4 93.5 93.7 94.3 94.5 94.7 95.2 96.3 95.9 95.7 96.2 97.4 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 62104100245115

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) 70 10070

60 60 80 50 50 60 40 40

30 3040

20 20 10 10 0 0 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 40 41 39 30 47 27 44 24 44 40 23 33 30 31 34 29 29 31 32 38 37 30 34 29

Quarterly rolling year Clostridium difficile Infection Cases per 1000 total occupied bed days for HEAT Target Measurement (Ages 65 & over) 0.45 0.4 0.35 0.3 2013 HEAT Target = 0.39 cases or less per 1000 total OBDs 0.25 0.2 0.15 0.1 0.05 0 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13 Jan 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Dec 11 Jun 12 Sept 12 Dec 12 Mar 13

Apr 10 - Jul 10 - Oct 10 - Apr 11 - Mar 11 Jun 11 Sept 11 Mar 12 A ct ual Perf ormance 0.33 0.30 0.26 0.23 0.24 0.24 Target 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39

Quarterly rolling year Staphylococcus aureus Bacteraemia Rates per 1000 Acute Occupied Bed Days for HEAT Target Measurement 0.35

0.3

0.25

0.2

0.15 2013 HEAT Target = 0.26 cases or less per 1000 acute OBDs

0.1

0.05

0 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Jul 10 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Jun 11 Jun 12 Sept 12 Dec 12 Mar 13 0.328 0.325 0.312 0.300 0.283 0.288 Apr0.26 10 - 0.26Oct 0.26 10 - Jan 0.26 11 - Apr 0.26 11 - 0.26 0.26 0.26 0.26 Mar 11 Sept 11 Dec 11 Mar 12 A ct ual Perf ormance Target

Healthcare Associated Infection Reporting Template (HAIRT) Section 2 – Healthcare Associated Infection Report Cards The following section is a series of ‘Report Cards’ that provide information, for each acute hospital and key community hospitals in the Board, on the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up to date information on HAI activities at local level than is possible to provide through the national statistics.

Understanding the Report Cards – Infection Case Numbers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data are presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139§ionID=1

Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252§ionID=1 For each hospital the total number of cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out of hospital” report card. Understanding the Report Cards – Hand Hygiene Compliance Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/ Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital report card presents the percentage of hand hygiene compliance for all staff in table form.

Understanding the Report Cards – Cleaning Compliance

Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ The first page of each hospital Report Card gives the hospitals cleaning compliance percentage in table form.

Understanding the Report Cards – ‘Out of Hospital Infections’ Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries and care homes and hospices. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.

Glasgow Royal Infirmary / Princess Royal Maternit y Total Staphylococcus aureus Bacteraemia Cases (all ages)

Data presented for Clostridium difficile Infection cases in ages 15 & over, 10

Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia cases & 8 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases.HEAT target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene 6 Compliance- monthly compliance greater than 94%. Cleaning Compliance - 4 monthly compliance greater than 92%. Estates Monitoring -monthly compliance across NHSGGC greater than 93%. 2 N.B. New Domestic & Estates monitoring compliance format introduced by Health Facilities Scotland in April 2012. 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 455825395415 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 97 95 95 97 98 97 94 97 97 97 97 97 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 95.1 95.1 94.5 94.7 94.8 94.7 95 93.7 95.3 95.4 95.3 95.1 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12(%) J u n - 12 J u l - 12 A u g - 12 0 93.7 95.6 96 95.8 96.5 96.5 96.4 97.5 97.7 97.8 97.2 96.9 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 000000011000

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) 10 10010

8 808

6 606

40 4 4

20 2 2 0 0 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 351562424212 455825384415

Royal Alexandra Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

10 Data presented for Clostridium difficile Infection cases in ages 15 & over, Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia cases & 8 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases. HEAT 6 target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene Compliance- monthly compliance greater than 93%. 4 Cleaning Compliance -monthly compliance greater than 93%. N.B. New Domestic & Estates monitoring compliance format introduced by 2

Health Facilities Scotland in April 2012. 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 312002330044 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 97 96 98 98 93 98 96 97 97 97 96 97 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 94.7 94.6 95 94.9 95 95.2 95.7 95.3 96.2 94.1 95.1 95.3 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12 (%) J u n - 12 J u l - 12 A u g - 12 0 96.7 93.2 94.4 93.7 94.2 95 97.4 95.2 98.4 98.4 98.3 97.6 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 002000120000

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) 10 10010

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 013042224211 310002210044

Inverclyde Royal Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

This report card contains information for Inverclyde Royal Hospital including the 10 Larkfield Unit.Data presented for Clostridium difficile Infection cases in ages 15 & over, Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia cases 8 & Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases. 6 HEAT target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene Compliance- monthly compliance greater than 93%. 4 Cleaning Compliance -monthly compliance greater than 95%. 2 Estates Monitoring -monthly compliance across NHSGGC greater than 89%.

N.B. New Domestic & Estates monitoring compliance format introduced by 0 Health Facilities Scotland in April 2012. Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 001201001120 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 95 95 93 98 98 99 98 99 98 99 99 99 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 95.5 95.7 95.1 95.5 95.4 95.8 95.7 N A 95.6 95.7 95.3 95.9 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12 (%) J u n - 12 J u l - 12 A u g - 12 0 91.8 91.6 91 92.1 90.9 91.5 92.5 N A 89.9 97 96.2 98.4 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 001000000000

10 Clostridium difficile Cases (ages 15 and over)10010 MSSA Bacteraemia Cases (all ages)

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 201100101125 000201001120

Victoria Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages)

This report card contains information for the Victoria Infirmary, New Victoria 10 Hospital(ACAD)& the Mansionhouse Unit. Data presented for Clostridium difficile Infection cases in ages 15 & over, Meticillin Sensitive Staphylococcus aureus 8 (MSSA) Bacteraemia cases & Meticillin Resistant Staphylococcus aureus 6 (MRSA) Bacteraemia cases. HEAT target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene Compliance- monthly compliance greater than 96%. 4 Cleaning Compliance -monthly compliance greater than 93%. Estates Monitoring -monthly compliance across NHSGGC greater than 90%. 2

N.B. New Domestic & Estates Monitoring Compliance format introduced by 0 Health Facilities Scotland in April 2012. Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 521302321013 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 9799969910096969798989898 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 95.1 95.3 95.5 94.1 93.6 94 94.5 95.8 95.4 94.7 94.3 93.1 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12Compliance A p r - 12 M a y - 12(%) J u n - 12 J u l - 12 A u g - 12 0 92.1 92.4 92.6 90.8 95.4 95.2 96.2 97.6 97.1 98.5 98 97.1 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 311000000001

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) 10 10010

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 220013310123 210302321012

Southern General Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

This report card contains information for the Southern General Hospital, 10 including the Langlands Unit & New South Glasgow Hospitals. Data presented for Clostridium difficile Infection cases in ages 15 & over, Meticillin Sensitive 8 Staphylococcus aureus (MSSA) Bacteraemia cases & Meticillin Resistant 6 Staphylococcus aureus (MRSA) Bacteraemia cases.HEAT target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene Compliance- monthly 4 compliance greater than 95%. Cleaning Compliance -monthly compliance 2 greater than 91%. Estates Monitoring -monthly compliance across NHSGGC

greater than 92%. N.B. New Domestic & Estates Monitoring Compliance format 0 introduced by Health Facilities Scotland in April 2012. Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 212234013014 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 96 95 95 98 95 98 97 96 98 97 97 98 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 94.8 94.7 94.1 93.3 93.4 93.4 93.6 N A 91.5 94.3 94.8 95.5 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12(%) J u n - 12 J u l - 12 A u g - 12 0 92.4 92.8 92.1 93.9 93.5 93.8 95.1 N A 97.6 97.7 99 99.4 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 101220001001

Clostridium difficile 10 Cases (ages 15 and over)10010 MSSA Bacteraemia Cases (all ages)

8 808

6 606

4 40 4

2 20 2

0 0 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 204314223423 111014012013

Western Infirmary Total Staphylococcus aureus Bacteraemia Cases (all ages)

Data presented for Clostridium difficile Infection cases in ages 15 & over, 10

Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia cases & 8 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases.HEAT target achieved for both 2011 revised CDI & SAB targets. 6 Hand Hygiene Compliance- monthly compliance greater than 93%. 4 Cleaning Compliance -monthly compliance greater than 94%. Estates Monitoring -monthly compliance across NHSGGC greater than 96%. 2 N.B. New Domestic & Estates monitoring compliance format introduced by Health Facilities Scotland in April 2012. 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 310222113500 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 93 97 94 98 96 98 96 98 96 95 97 97 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 95.4 95.4 94.6 94.8 95.8 96.3 94.6 95.3 95 94.8 95.1 95.5 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12(%) J u n - 12 J u l - 12 A u g - 12 0 98.7 98.9 98.3 98.6 98.4 98.9 99 98.6 97.5 95.5 96.9 98.2 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 000100001000

Clostridium difficile 10 Cases (ages 15 and over)10010 MSSA Bacteraemia Cases (all ages)

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 332212126111 310122112500

Gartnavel General Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages) This report card contains information for Gartnavel General Hospital, including 10 the Bestson Oncology & Homeopathic Hospital. Data presented for Clostridium difficile Infection cases in ages 15 & over, Meticillin Sensitive Staphylococcus 8 aureus (MSSA) Bacteraemia cases & Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases. HEAT target achieved for both 2011 revised 6

CDI & SAB targets. Hand Hygiene Compliance- monthly compliance greater 4 than 95%. Cleaning Compliance -monthly compliance greater than 93%. 2 Estates Monitoring -monthly compliance across NHSGGC greater than 87%. 0 N.B. New Domestic & Estates Monitoring Compliance format introduced by Health Facilities Scotland in April 2012 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 Hand Hygiene Monitoring Compliance (%) 123211411400

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 MRSA Bacteraemia Cases (all ages) 98 98 95 98 97 96 95 98 99 98 98 99

Cleaning Compliance (%) 8

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 94.7 95.1 95.4 95.6 95.4 95 94.7 96.1 95.5 95.9 94.8 96 4

2 Estates Monitoring Compliance (%)

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 0 87.7 87.5 91.4 94.8 93.5 93.1 91.5 92 97.7 95.1 96.9 94.2 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 000110000000

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

10 10010

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 454200212311 123101411400

Vale of Leven Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

Data presented for Clostridium difficile Infection cases in ages 15 & over, 10 Meticillin Sensitive Staphylococcus aureus(MSSA) Bacteraemia cases & Meticillin Resistant Staphylococcus aureus(MRSA) Bacteraemia cases. HEAT 8 target achieved for both 2011 revised CDI & SAB targets. 6 Hand Hygiene Compliance- monthly compliance across NHSGGC greater than 93%. 4 Estates Monitoring -monthly compliance across NHSGGC greater than 87%. 2 Cleaning Compliance -monthly compliance across NHSGGC greater than 94%.

N.B. New Domestic & Estates monitoring compliance format introduced by 0 Health Facilities Scotland in April 2012. Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 000000000000 Hand Hygiene Monitoring Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 99 99 99 99 99 95 97 100 100 100 98 99 MRSA Bacteraemia Cases (all ages) 10

8 Cleaning Compliance (%) S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 95.3 94.5 94.5 95 94.4 94.1 94.6 97.3 93.4 94.7 94.6 95.1 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11Estates J a n - 12 Monitoring F e b - 12 M a r - 12 Compliance A p r - 12 M a y - 12(%) J u n - 12 J u l - 12 A u g - 12 0 91 91 88 89.8 87.3 89.2 89.7 97.2 98 97.3 99 99.1 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 000000000000

10 Clostridium difficile Cases (ages 15 and over)10010 MSSA Bacteraemia Cases (all ages)

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 100010000010 000000000000 Total Staphylococcus aureus Bacteraemia Cases (all ages) Royal Hospital for Sick Children(Yorkhill) Data presented for Clostridium difficile Infection cases in ages 15 & over, Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia cases & 10 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia cases. HEAT 8 target achieved for both 2011 revised CDI & SAB targets. Hand Hygiene Compliance - monthly compliance greater than 93%. 6 Cleaning Compliance -monthly compliance greater than 93%. Estates Monitoring -monthly compliance across NHSGGC greater than 96%. 4

N.B. New Domestic & Estates monitoring compliance format introduced by 2 Health Facilities Scotland in April 2012. 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 Hand Hygiene Monitoring Compliance (%) 012010332221

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 MRSA Bacteraemia Cases (all ages) 99 98 97 99 97 96 97 93 98 98 100 97

Cleaning Compliance (%) 8

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 6 96.1 94.9 95.2 94.7 94.8 94.2 93.9 95 95.2 95.4 94.7 96.2 4

2 Estates Monitoring Compliance (%)

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 0 96.3 97.2 98.5 98.3 98.7 97.8 97.5 98.4 98.4 98.2 98.2 98.8 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 000000100000

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

10 10010

8 808

6 606

40 4 4

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 000000000000 012010232221

Community Hospitals [Non Acute & Mental Health Hospitals] Clostridium difficile Infection Cases

This is an amalgamation of data from the following hospitals: Lightburn,Drumchapel,Gartnavel Royal, Parkhead, Ravenscraig, Blawarthill, 3 Leverndale, Johnstone, Mearnskirk, Dykebar Hospitals and as of May 2011, Stobhill Hospital. These hospitals are non acute hospitals & mental health hospitals and have very few cases to report. 2 Data for Clostridium difficile Infection cases in ages 15 & over, Data presented for Meticillin Sensitive Staphylococcus aureus Bacteraemia cases & Meticillin Resistant Staphylococcus aureus Bacteraemia cases. NHSGGC successfully 1 achieved both HEAT target requirements by 31st March 2011.

0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 012011011100

MSSA Bacteraemia Cases MRSA Bacteraemia Cases 5 5

4 4

3 3

2 2

1 1

0 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 000010000100 100000100000

Out of Hospital Infections Clostridium difficile Infection Cases

Data for Clostridium difficile Infection cases in ages 15 & over: 30

57.9% of all CDI cases reported in NHSGGC September 2011 to August 25 2012 are attributed as Out of Hospital infections.

20 Out of Hospital MSSA bacteraemias account for 57% of all cases from September 2011 to August 2012. Out of Hospital MRSA bacteraemias 15 make up 44% of all cases for the same timeframe. 10 This equates to 55.5% of all Staphylococcus aureus Bacteraemia cases being Out of Hospital infections. 5

0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 23 24 22 17 32 13 29 13 23 25 12 17

MSSA Bacteraemia Cases MRSA Bacteraemia Cases

40 40

35 35

30 30

25 25

20 20

15 15

10 10

5 5

0 0 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug -12

S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J u n - 12 J u l - 12 A u g - 12 S e p - 11 O c t - 11 N o v - 11 D e c - 11 J a n - 12 F e b - 12 M a r - 12 A p r - 12 M a y - 12 J un- 12 J ul - 12 A ug - 12 16 19 23 14 22 14 16 21 24 13 23 14 1 1 5 0 7 0 0 1 2 1 1 3

Statistical Process Chart (SPC) Appendix 1

This section includes Hospital level SPCs for acute sites in NHSGGC

The SPCs include data on • Hospital Acquired MRSA cases (includes wound swabs, sputum & urine samples etc.) • Hospital Acquired Clostridium difficile cases

Surveillance data can be used to detect any change in the incidence of disease, which in turn facilitates the early identification outbreaks of infection and leads to prompt initiation of preventive measures. It also allows local infection control teams to focus their interventions in areas where the greatest benefit to patients can be achieved.

Statistical Process Control Charts (SPCs) are the application of statistical theory to Quality Control. They show process data chronologically (per month in most cases). Some examples of where they have been used in healthcare include; queuing analysis of appointment access and delays and forecasting bed needs.

The most common use for SPCs in infection control practice is in relation to healthcare acquired MRSA and C. difficile infections. Calculations are made based upon the ward/unit’s historical infection rate to produce 3 lines, the upper and lower control limits and the centre line (mean). The setting of the upper control limits allows the local teams to ‘trigger’ actions promptly in response to any increase in the number of patients identified.

This is an SPC showing only Natural Variation (Note on this chart all the result s are within the control limits)

25.0 Centre Line Most 20.0 (CL) or mean Recent The Upper and Lower Result Control limits (UCL/LCL). 15.0 Res CL UCL LCL 10.0

5.0 Results

0.0

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 00 00 00 -200 -200 -200 -20 -20 -20 -200 -200 -200 -2 -20 -20 -2002 -200 -200 -200 -2 -20 -20 -2002 -200 -200 -2 -20 5 5 5 7 7 7 8 8 9 0 -04 -05 -05 -06 -06 -06 -07 -08 -08 -08 -09 -09 -09 6-06 25 02 09 16-0 23-0 30-0 0 13 20 27 04-0 11-0 18-0Time25 01 Units08 15 22-0 29-0 05-0 12 19 26 03-1

Although SPCs are a method of viewing what is going on at a local level the SPC can also be used to drive improvements in care. This is shown by reducing the mean (centre line) which indicates that fewer patients are acquiring infection in our wards and hospitals.

25.0

20.0

15.0 Res CL

UCL LCL

10.0

5.0

0.0 25/04/2002 09/05/2002 23/05/2002 06/06/2002 20/06/2002 04/07/2002 18/07/2002 01/08/2002 15/08/2002 29/08/2002 12/09/2002 26/09/2002

This chart demonstrates that infection control practice on a ward has improved. This in turn has resulted in fewer cases and the mean for this ward has been reduced to reflect this. Now that SPC’s are available across the whole of NHSGGC we will be actively targeting improvements in areas with historically high levels of infection and sustaining improvements in areas with low infection rates.

Trigger Events/Charts that Breach the Upper Control Limits

An SPC will only identify that a problem exists – it will not identify what is causing the problem. If a chart is seen to be above the upper control limit the ICT with the local clinical team will review the area to determine the likely cause and develop appropriate action plans.

All Hospital Level Statistical Process Control Charts remain within normal control limits.

Glasgow Royal Infirmary

Royal Alexandra Hospital

Inverclyde Royal Hospital

Victoria Infirmary

Southern General Hospital

Western Infirmary

Gartnavel General Hospital

Vale of Leven Hospital

GLOSSARY

ACDP Advisory Committee on Dangerous Pathogens AMT Antimicrobial Management Team AOD Acute Operating Division Alert organism alert Any of a number of organisms or infections that could indicate, or cause, outbreaks of infection in the hospital condition or community. Bacteraemia Infection in the blood. Also known as Blood Stream Infection (BSI). BICC Board Infection Control Committee CDAD Clostridium difficile Associated Disease CDI Clostridium difficile Infection CEL Chief Executive Letter issued by Scottish Government Health Directorates (SGHD) CMO Chief Medical Officer CVC Central Vascular Catheter C. difficile Clostridium difficile also referred to as C. diff (or C-diff) is a Gram-positive spore-forming anaerobic bacteria. C. difficile is the commonest cause of gastro-intestinal infection in hospitals. It causes two conditions; antibiotic associated diarrhoea and the more severe and occasionally life-threatening pseudomembranous colitis. Control of the organism can be problematic due to the formation of spores and difficulty in removing them. Patients who have had antibiotics within the last eight weeks are most at risk of acquisition of the organism. Cleanliness Cleanliness Champion Champion A Ministerial led initiative to offer a specific education programme to HCWs. http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/19529/19322 Code of Practice Code of Practice The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection issued 2004 contains the components that must be complied with by all NHS HCWs in Scotland. http://www.scotland.gov.uk/Publications/2004/05/19315/36624 GRO General Registers Office HAI Originally used to mean hospital acquired infection, the official ‘Scottish Government’ term is now Healthcare Associated Infection. These are considered to be infections that were not incubating prior to contact with a healthcare facility or undergoing a healthcare intervention. It must be noted that HAI infection is not always an avoidable infection. HAI SCRIBE Scottish Health Facilities Note 30: version 3. Infection Control in Built Environment: Design and Planning. &HBN 30 HCW Healthcare Worker HDL Health Department Letter HEAT Target Health Efficiency and Access to Treatment. Targets set by the Scottish Government. HH Hand Hygiene HPS Health Protection Scotland ICN/T/O/D/M Infection Control Nurse / Team / Officer / Doctor / Manager ICP Infection Control Programme KPI Key Performance Indicator LHBC Local Health Board Co-ordinator (Hand Hygiene) MRSA Meticillin resistant Staphylococcus aureus. A Staphylococcus aureus resistant to first line antibiotics; most commonly known as a hospital acquired organism. MSSA Meticillin Sensitive Staphylococcus aureus NCIC Nurse Consultant Infection Control PCAT Primary Care Audit Tool PFPI Public Focus Patient Involvement PHPU Public Health Protection Unit PPI Public Partners Involvement PVC Peripheral Vascular Catheter QIS Quality Improvement Scotland SIRN Scottish Infection Research Network SOP Standard Operating Procedure SPC Statistical Process Control Charts SPSP Scottish Patient Safety Programme SSI Surgical Site Infection VRE Vancomycin resistant enterococcus - an alert organism A common organism that can be inherently resistant to Vancomycin but can also acquire (and transfer resistance) to other organisms. Has caused outbreaks reported in the literature in a variety of high-risk settings, e.g. renal or bone marrow transplant units.

ANNUAL INFECTION PREVENTION & CONTROL PROGRAMME 2012 / 2013

This programme may be altered if significant new risks are identified, or resources do not allow the activity to be undertaken.

Approval NHS Greater Glasgow & Clyde Board Infection Control Manager NHS Greater Glasgow & Clyde Board Infection Control Committee NHS Greater Glasgow & Clyde Chief Executive

Submitted to: NHS Greater Glasgow & Clyde Acute Infection Control Committee NHS Greater Glasgow & Clyde Partnerships Infection Control Support Group

INTRODUCTION

Welcome to the 2012/13 NHS Greater Glasgow and Clyde Infection Control Programme. This Programme has been developed on behalf NHS Greater Glasgow & Clyde by the Board Infection Control Committee.

The Infection Control Programme exists to co-ordinate and monitor the work of the Infection Control Committees and Teams in preventing and controlling infection through effective communication, education, audit, surveillance, risk assessment, quality improvement and development of policies and procedures. The Programme addresses the national and local priorities for infection prevention and control and extends throughout healthcare, health protection and health promotion. Operational delivery if the programme is regularly monitored and reviewed through the detailed implementation plan (section 8

The programme and associated implementation plan require all disciplines to work together to promote good infection prevention and control. Central to these efforts are the detailed work plans, governance systems and monitoring and reporting arrangements for the effective prevention and control of infection across NHSGGC.

Infection prevention and control clearly does not rest solely within the domains of our Infection Control Committees and Teams. Everyone has infection prevention and control responsibilities. Service users who depend on NHS Greater Glasgow and Clyde require all of us to follow best practice as described in the NHS Greater Glasgow and Clyde Infection Prevention and Control Manual www.nhsggc.org.uk/infectioncontrol.

The Infection Control Committees will co-ordinate delivery of this extensive body of work. Please ensure you all assist through your own infection prevention and control actions whether delivering or receiving healthcare.

Tom Walsh Infection Control Manager

NHS GREATER GLASGOW AND CLYDE

For more information on hand hygiene see: www.washyourhandsofthem.com

CONTENTS

1. KEY PRIORITY AREAS NHS GREATER GLASGOW AND CLYDE ……………………… 1 2. NATIONAL PROGRAMMES/MANDATORY REQUIREMENTS …………………………… 1 3. ADDITIONAL RECOMMENDED ELEMENTS ……………………………………………….. 2 4. SECTION 1 - ACTIONS REQUIRED TO MEET KEY PRIORITY AREAS ……………….. 2 5. SECTION 2 - ACTIONS REQUIRED TO MEET NATIONAL AND MANDATORY REQUIREMENTS …………………………………………………………. 3-6 6. SECTION 3 - ADDITIONAL RECOMMENDED ELEMENTS …………………………….. 7 7. GLOSSARY ……………………………………………………………………………………. 8

1. KEY PRIORITY AREAS NHS GREATER GLASGOW AND CLYDE

Requirement Action to be taken by HEAT Target – to reduce MRSA/MSSA bacteraemias to NHSGGC Board 0.26 cases per 1000 Occupied Bed Days by 2013. (T11) Quality Improvement Scotland (QIS) Healthcare Associated NHSGGC Board Infection (HAI) Standards – Implement systems and processes to meet the above standards and ensure that all sites in NHSGGC are demonstrating compliance with the standards. Implement change in response to requirement/recommendations for improvement recommended in HEI reports. Hand Hygiene - As per CMO(2007)1 NHSGGC Board Include monthly results from each hospital site in the NHSGGC Healthcare Associated Infection Reporting Template HEAT Target to reduce C. difficile infections to 0.39 cases NHSGGC Board per 1000 Occupied Bed days by 2013. (T11)

2. NATIONAL PROGRAMMES/ MANDATORY REQUIREMENTS

Requirement Action to be taken by Prepare bi-monthly report on infection control activity Board Medical Director within NHSGGC (HAIRT & HAI monthly report card). Board Infection Control Manager Topic – Surveillance NHSGGC Board As per HDL(2006)38 and CEL 11(2009) Topic – Education Infection Control Education QIS HAI Standards – Section 5. Sub-Group and NHSGGC A Framework for Mandatory Induction Training in HAI for Learning and Education NHS Scotland. Department Topic – Policies NHSGGC Board To produce service-wide policies and guidance which are evidence based and comply with national priorities. To implement chapter 1 of the National IPC Policy Manual by June 2012 Topic – Decontamination Estates & Facilities Division To comply with national directives/ standards on Decontamination Sub-Group & decontamination. CJD Sub-Group Topic – Clinical Governance Board Medical Director Develop an annual Infection Prevention and Control Report Board Infection Control for approval by the NHSGGC Board Clinical Governance Manager Committee. Head of Clinical Governance To comply with the principles outlined in the QIS Clinical Governance and Risk Management Standards. Topic – Patient Safety NHSGGC Board Scottish Patient Safety Programme – To support the delivery of the HAI elements of the programme. Topic – Cleaning Estates & Facilities Directorate To comply with the National Cleaning Services Specification. Topic – Built Environment Estates & Facilities Division To plan to achieve compliance with HAI SCRIBE & HBN 30 NCIC New Build and Local and any other building notes as required. IPCTs Topic – Antimicrobial NHSGGC Antimicrobial Support the work of the Antimicrobial Management Team in Utilisation Committee promoting prudent antimicrobial prescribing across NHSGGC. CEL11(2009) and CEL 30 (2008) and QIS HAI Standard 3.

3. ADDITIONAL RECOMMENDED ELEMENTS

Requirement Action to be taken by

Topic – Patient Experience NHSGGC Board NHSGGC must secure public involvement in issues related to HAI and have systems and processes in place to link this to the Patient Experience Group. Topic – Research ALL NHSGGC will collaborate with SIRN, Universities and other relevant organisations to take forward research initiatives.

4. SECTION 1 –

ACTIONS REQUIRED TO MEET KEY PRIORITY AREAS

Objective: To reduce MRSA/ MSSA Bacteraemia to 0.26 cases per 1000 OBD by 2013 Objective to be achieved by the following Action by Timescale actions Continue the enhanced surveillance of MRSA/ IPCT Ongoing MSSA bacteraemia. In areas with a high incidence of MRSA/ MSSA IPCT Ongoing bacteraemia, produce action plans in collaboration with clinical teams to reduce incidence including the use of CVC/ PVC Care Bundles. Produce a report on the incidence and possible IPCT Ongoing causes of MRSA/ MSSA bacteraemia for distribution to the SAB group and the AICC. Assist clinical teams in completing the SAB RCA to IPCT/ Directorate Ongoing support improvement where possible. Teams

Objective: To meet QIS Healthcare Associated Infection/HEI Standards Objective to be achieved by the following Action by Timescale actions NHSGGC HEI Steering group will prepare action Acute Division MHP Ongoing plans and monitor NHSGGC progress against in-patient sites these actions in response to site specific HEI reports.

Objective: Adopt a ‘zero tolerance’ approach to non-compliance with Hand Hygiene Objective to be achieved by the following Action by Timescale actions To continue to support staff to undertake local HH NHSGGC Board Ongoing audits based on SPSP methodology which will now (LHBC) include information on technique as well as opportunity. Continue to recruit members of the public to NHSGGC Board participate in hand hygiene audits. (LHBC)

Objective: To reduce CDI to 0.39 cases per 1000 OBD by 2013) Objective to be achieved by the following Action by Timescale actions Continue production and feedback of C. difficile IPCT Ongoing Statistical Process Control Charts (SPCs). Produce monthly directorate reports detailing areas IPCT Ongoing with the highest prevalence and actions advised to reduce numbers. Produce reports on compliance with antimicrobial AMT Ongoing prescribing guidelines.

5. SECTION 2 –

ACTIONS REQUIRED TO MEET NATIONAL AND MANDATORY REQUIREMENTS

SURVEILLANCE AND QUALITY IMPROVEMENT PROGRAMMES

Objective: To undertake surveillance and quality improvement programmes which are compliant with national requirements and which are designed to achieve reductions in HAI Objective to be achieved by the following Action by Timescale actions NHSGGC will comply with HDL(2006)38 and IPCT Ongoing CEL 11(2009).

IPCT will carry out Alert organism/ condition IPCT Ongoing surveillance. MRSA and C. difficile SPCs will be issued IPCT Ongoing monthly to all in-patient areas within NHSGGC.

Prepare a report on infection control activities IPCT Monthly and exceptions for each directorate within NHSGGC.

Prepare Surgical Site Infection (SSI) reports for IPCT Monthly and as the acute service based on the mandatory SSI required surveillance but also specific SSI surveillance if requested by service users.

EDUCATION

Objective: To ensure that NHSGGC provides an educational framework for all HCWs Objective to be achieved by the following Action by Timescale actions Ensure that NHSGGC is compliant with the AMT, Learning and Ongoing elements outlined in the QIS/ HEI HAI Education and Standards and continue to support the learning Acute Division - HEI and education mandatory update sessions. Steering Group.IPCT (standard 5).

Online educational programmes with NHSGGC IPC Education Ongoing associated assessments will continue to be Sub-Group and updated and will reflect the general as well as Education Lead the specific educational needs of the workforce.

IPCT will continue to support a single Infection NHSGGC IPC Education Ongoing Control Induction Programme for staff Sub-Group Learning and throughout NHSGGC. Education for NHSGGC

Provide ongoing education to support and NHSGGC IPC Education Ongoing develop the Cleanliness Champions and the Sub-Group and Senior Charge Nurses in NHSGGC. Education Lead

POLICIES

Objective: To maintain and enhance the NHSGGC Infection Prevention and Control Policy Manual Objective to be achieved by the following Action by Timescale actions There will be a planned programme for the NHSGGC IPCN Ongoing review/ updating of all policies as per QIS HAI Policy Sub-Group Standards.

The planned programme for the auditing of IPCT Ongoing Infection Control Policies will continue.

New policies will be developed as identified by Ongoing Ongoing the organisation.

DECONTAMINATION

Objective: To comply with national and EU regulations regarding decontamination Objective to be achieved by the following Action by Timescale actions NHSGGC will evaluate the impact of PCAT and Decontamination Sub- 2013 implement action plans to meet Group, Facilities Division recommendations. & IPCT Partnerships

Implement the planned replacement Decontamination Sub- Ongoing programme for endoscopy services. Group, Facilities Division

Review assessment documentation in relation NHSGGC CJD Ongoing to the updated Advisory Committee on Sub-Group Dangerous Pathogens (ACDP) guidance on “transmissible spongiform encephalopathy agents: safe working and the prevention of infection”. http://www.dh.gov.uk/ab/ACDP/TSEguidance/in dex.htm

Support the work of the NHSGGC IC IC Decontamination Ongoing Decontamination Sub-Group (sub-group of Sub-Group BICC) to address operational/ technical issues and give advice accordingly.

CLINICAL GOVERNANCE

Objective: To comply with the principles outlined in the QIS Clinical Governance and Risk Management Objective to be achieved by the following Action by Timescale actions Infection control service will have structures Board Medical Director Ongoing and processes in place to identify, manage and Board Infection Control communicate risks throughout the organisation. Manager

Use Datix clinical risk management system to All Ongoing report specific HAI incidents.

Use Datix to trigger RCA for cases of severe All Ongoing CDI or cases where CDI appears on any part of the patient’s death certificate.

Use Datix to trigger RCA for cases of All April 2012 staphylococcus aureus bacteraemia.

ICM or designated representative attends ICM Ongoing NHSGGC Board and Acute Clinical Governance Committees and provides updates and assurance in relation to infection prevention and control.

Provide bi-monthly reports to the NHSGGC ICM Ongoing Quality and Performance Committee.

Produce an Annual Report based on the ICP for ICM March 2013 approval by the Board Clinical Governance Committee.

Produce bi-monthly reports on HAI KPIs for the ICM Ongoing NHSGGC Board meetings.

PATIENT SAFETY

Objective: To ensure that patients are cared for in a safe environment Objective to be achieved by the following Action by Timescale actions The IPCTs in NHSGGC will participate in the All Ongoing Scottish Patient Safety Programme in both acute and partnership areas.

The Infection Control Safe Patient Environment IPCT Ongoing Audit will be undertaken in all clinical areas as a minimum yearly (green) or more frequently as indicated by the score i.e. 6 months (amber) or 3 months (red).

A system will be put in place to collate and IPCT December 2012 review the action plans produced by SCN/ Estates in response to environmental audits and assist lead nurses/ SCN to put these actions in place.

Information available via servicetrack (IT IPCT August 2012 system to support the environmental audits) will be analysed to provide information on trends across directorates/ sites.

HEALTHCARE HYGIENE & CLEANING SERVICES

Objectives: To comply with national guidance on cleanliness standards and provide patients and visitors with a clean hospital environment Objective to be achieved by the following Action by Timescale actions To ensure compliance with national monitoring NHSGGC Estates & Ongoing of standards. Facilities Division HAI Lead

To ensure compliance with the educational NHSGGC Estates & Ongoing framework for domestic assistants. Facilities Division HAI Lead

To ensure compliance with peer and public NHSGGC Estates & Ongoing review of the service. Facilities Division HAI Lead

To facilitate the training of peer and public NHSGGC Estates & Ongoing reviewers. Facilities Division HAI Lead

BUILT ENVIRONMENT

Objective: To ensure that NHSGGC premises are designed and built to facilitate the prevention and control of infection. Objective to be achieved by the following Action by Timescale actions HAI Scribe, HBN 30 and CEL 27 (2010) Single NHSGGC Estates & Ongoing Room Accommodation & Bed Spacing will be Facilities Division/ NCIC applied to the construction of new buildings and the renovation of existing facilities.

AICC will review the legislation and actions AICC Ongoing required in relation to the control of Legionella and the monitoring of theatre ventilation.

Ventilation Sub-Group will provide assurance Ventilation Sub-Group – Ongoing that theatre areas within NHSGGC meet sub-group of AICC required standards.

ANTIMICROBIAL PRESCRIBING

Objective: To support the work of the Antimicrobial Management Team in promoting prudent antimicrobial prescribing across NHSGGC and achieving the actions outlined in CEL11(2009) and CEL 30 (2008). Objective to be achieved by the following Action by Timescale actions Support the Antimicrobial Management Team AMT, NHSGGC Ongoing in promoting antimicrobial policies which limit broad spectrum antibiotics agents implicated in Clostridium difficile (CEL 11(2009)), MRSA and other similar infections.

Use IC data in relation to C. difficile and MRSA AMT, IPCT Ongoing to quantify the effect of the implementation of the NHSGGC Infection Management Guideline and the CDAD Management Guidance.

Continue to support the application of guidance/ AMT Ongoing policies in NHSGGC to meet the requirements of CEL 30(2008) prudent antimicrobial prescribing: the Scottish Action Plan for managing antibiotic resistance and reducing antibiotic related CDAD CEL 11(2009).

6. SECTION 3 –

ADDITIONAL RECOMMENDED ELEMENTS

PATIENT EXPERIENCE

Objective: To ensure that systems and processes are in place to secure public involvement in issues related to HAI and that these systems are linked to the NHSGGC Patient Experience framework Objective to be achieved by the following Action by Timescale actions Representative from the IPCT will attend the IPCT Ongoing Acute Operating Divisions Patient Experience Steering Group.

The Annual IC Programme and the Annual IPCT Ongoing Report will be circulated to the AOD Patient Experience Steering Group for comment and information.

Any patient information that is updated or IPCT Ongoing developed will be circulated to the Community Engagement Managers for review by the Patients Panel and the Patient Experience leads in the CH(C)Ps.

A newsletter detailing HAI news and initiatives IPCT Ongoing will be developed and issued twice-yearly to the Communications Team and the CH(C)Ps Public Partnership Forums.

Participate in NHSGGC outreach events that IPCT Ongoing aims to involve the public in influencing services provided.

Members from the IPCT will continue to IPCT Ongoing participate in the Monitoring Framework for Cleaning Services PPI Review Support Group.

Public representatives will continue to sit on the IPCT Ongoing Board Infection Control Committee.

RESEARCH

Objective: To identify research opportunities in NHSGGC and support individuals/ teams to achieve their objectives Objective to be achieved by the following Action by Timescale actions IPCT Research Group will support and NHSGGC Ongoing encourage HAI research.

NHSGGC will collaborate with SIRN, NHSGGC Ongoing Universities and other relevant organisations to take forward applied and translational research initiatives.

7. GLOSSARY

ACDP Advisory Committee on Dangerous Pathogens AMT Antimicrobial Management Team AOD Acute Operating Division Alert organism Any of a number of organisms or infections that could indicate, or cause, outbreaks of alert condition infection in the hospital or community. Bacteraemia Infection in the blood. Also known as Blood Stream Infection (BSI). BICC Board Infection Control Committee CDAD Clostridium difficile Associated Disease CDI Clostridium difficile Infection CEL Chief Executive Letter issued by Scottish Government Health Directorates (SGHD) CMO Chief Medical Officer CVC Central Vascular Catheter C. difficile Clostridium difficile also referred to as C. diff (or C-diff) is a Gram-positive spore- forming anaerobic bacteria. C. difficile is the commonest cause of gastro-intestinal infection in hospitals. It causes two conditions; antibiotic associated diarrhoea and the more severe and occasionally life-threatening pseudomembranous colitis. Control of the organism can be problematic due to the formation of spores and difficulty in removing them. Patients who have had antibiotics within the last eight weeks are most at risk of acquisition of the organism. Cleanliness Cleanliness Champion Champion A Ministerial led initiative to offer a specific education programme to HCWs. http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/19529/19322 Code of Practice Code of Practice. The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection issued 2004 contains the components that must be complied with by all NHS HCWs in Scotland. http://www.scotland.gov.uk/Publications/2004/05/19315/36624 GRO General Registers Office HAI Originally used to mean hospital acquired infection, the official ‘Scottish Government’ term is now Healthcare Associated Infection. These are considered to be infections that were not incubating prior to contact with a healthcare facility or undergoing a healthcare intervention. It must be noted that HAI infection is not always an avoidable infection. HAI SCRIBE Scottish Health Facilities Note 30: version 3. Infection Control in Built Environment: &HBN 30 Design and Planning. HCW Healthcare Worker HDL Health Department Letter HEAT Target Health Efficiency and Access to Treatment. Targets set by the Scottish Government. HH Hand Hygiene HPS Health Protection Scotland IPCN/T/O/D/M Infection Control Nurse / Team / Officer / Doctor / Manager ICP Infection Control Programme KPI Key Performance Indicator LHBC Local Health Board Co-ordinator (Hand Hygiene) MRSA Meticillin resistant Staphylococcus aureus. A Staphylococcus aureus resistant to first line antibiotics; most commonly known as a hospital acquired organism. MSSA Meticillin Sensitive Staphylococcus aureus PCAT Primary Care Audit Tool PHPU Public Health Protection Unit PVC Peripheral Vascular Catheter QIS Quality Improvement Scotland SIRN Scottish Infection Research Network SOP Standard Operating Procedure SPC Statistical Process Control Charts SPSP Scottish Patient Safety Programme VRE Vancomycin resistant enterococcus - an alert organism. A common organism that can be inherently resistant to Vancomycin but can also acquire (and transfer resistance) to other organisms. Has caused outbreaks reported in the literature in a variety of high- risk settings, eg renal or bone marrow transplant units.

The NHS Greater Glasgow & Clyde Infection Control Programme recognises that a wide variety of healthcare is undertaken in diverse settings and this may lead to additional initiatives being undertaken locally.