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SECTION 3 Description of the main areas of HAI work
This section of the report provides an overview of the most significant areas of work completed by the HAI Task Force over the last five years.
Implementation and Performance
One of the first areas of work for the HAI Task Force was the development and publication of the NHS Scotland Code of Practice for the Management of HAI and Hygiene. The purpose of this was to produce a good practice document which set out the key actions that NHS Boards should implement in order to tackle HAI. Arising from this was the development and funding to support the role of Infection Control Managers and Nurse Consultants in HAI who continue to play a key role in tacking healthcare associated infections.
The second phase of work saw a review of NHS Quality Improvement Scotland's HAI Infection Control Standards which provide a national framework for supporting the delivery of safe, effective, patient focused care and services. The final standards were published in March 2008.
Antimicrobial Prescribing
Resistance to antibiotics and other antimicrobials is recognised nationally and internationally as a major threat to public health and patient safety. MRSA is best known, but there is a raft of potentially more problematic resistant infections on the horizon. Prudent prescribing of antibiotics has a major role to play in the prevention and control of Clostridium difficile ( C. difficile) associated disease. The HAI Task Force aimed to address this in its first phase of work through providing guidelines to improve prescribing practices and this led to the publication of the Antimicrobial Prescribing Policy and Practice in Scotland, which was drafted by the Scottish Medicines Consortium for the HAI Task Force. These guidelines were issued to Boards in 2005 and recommend best practice, organisational structures and a comprehensive education programme for new and existing staff in this area.
This work was reviewed in the second phase of work and a more detailed plan was drawn up reflecting the importance of this area. This was published in February 2008 as the Scottish Management of Antimicrobial Resistance Action Plan (Scot MARAP) which expands upon the previous document and outlines the national programme for Scotland in tackling antimicrobial resistance over the next five years. The publication of Scot MARAP emphasises the need to establish a national clinical forum to take strategic responsibility for co-ordinating this programme and to implement the recommendations set out in the report through communicating and disseminating information. The Scottish Medicines Consortium ( SMC) has been identified as the organisation to convene and service this national clinical forum.
Cleaning, Hygiene and the Environment
A clean and hygienic healthcare environment is an essential part of preventing the spread of healthcare associated infections. The HAI Task Force's first Action Plan incorporated a wide range of activities, including the development and training framework for domestic assistants, guidance on reducing HAIs in the built environment and the development of a National Cleaning Services Specification and Monitoring Framework.
Education for cleaning staff was further developed in the second phase of the work, and the Monitoring Framework for theNHSScotland National Cleaning Services Specification was rolled out to all Health Boards in November 2005. Standards of hospital cleaning have improved as a result. All NHS Boards are compliant, with the most recent reports revealing that the all-Scotland compliance rate has increased to 95.6%.
Public Involvement
The HAI Task Force recognised that there was a need to engage the public in its work and develop communication pathways between the public and NHS Boards. During its first phase of work, the Task Force set up the Public Involvement and Communications Team ( PICT) with membership drawn from the general public. PICT has played an important part in the HAI Task Force's work and was active in many areas of both work programmes, such as NHS Scotland Code of Practice for the Management of HAI and Hygiene, the NHSScotland National Cleaning Services Specification and the Public Information Strategy.
Education and Training
The development of education and training programmes was another key priority area for the HAI Task Force during the first phase of the programme. Initial work included developing a national framework for mandatory induction training on HAI, with accompanying educational resources developed by NHS Education for Scotland ( NHSNES). Another key area of work was promoting and enlarging the Cleanliness Champions Programme. which was developed for staff from all sectors of the NHSScotland workforce. The programme was designed to promote the prevention and control of infection through equipping staff with the skills and knowledge they need to ensure good practice in areas fundamental to preventing HAI.
The Cleanliness Champions programme continued to be developed over the second phase of the programme, with its inclusion being promoted in the undergraduate nursing and medical courses. After the success of the introduction of induction training, NHSNES undertook the development of a national framework for post graduate and continuing professional development HAI education to ensure that healthcare staff continued to develop skills to combat HAIs throughout their careers. To date, over 4,500 Cleanliness Champions have completed their training
Hand Hygiene
Good hand hygiene is known to be one of the most important interventions in the prevention and reduction of avoidable HAIs. The first phase of the HAI Task Force programme developed national measures to support improved hand hygiene compliance. This involved measures such as educational resource packs developed by NHSNES, and was allocated to NHS Boards to provide alcohol hand rubs near every acute front line bed.
For the second phase of work, a national hand hygiene campaign was developed with Health Protection Scotland ( HPS) under the title "Germs - Wash Your Hands of Them". Launched in January 2007, The core aim of the Campaign was to drive the messages across to as wide an audience as possible about the importance of hand washing in preventing the spread of HAI, colds, flu, tummy bugs etc. HPS was commissioned to oversee the development and delivery of the Campaign and a Hand Hygiene Project Steering Board was set up to oversee its ongoing management. The Steering Board decided that the national Campaign should contain three strands to provide the public, the NHS and young children with a strong messages about the importance of good hand hygiene. The three strands consisted of:
- A six week TV and newspaper campaign which began on 15 January 2007. The evaluation of the campaign revealed that some 71 % of those polled would be more likely to wash their hands more often.
- A promotional campaign aimed at NHS Staff, patients and visitors, was launched alongside the public campaign in January 2007. This included the development and implementation of a tool to monitor hand hygiene compliance in NHS Boards. Posters and leaflets for the NHS environment - staff and visitors etc continue to be refreshed on a regular basis.
- The development of a Hand Hygiene Information Pack for nursery and primary school children. This element of the campaign was managed by a Schools and Nurseries Sub-Group consisting of representatives from the Scottish Government, Learning Teaching Scotland, HPS, Health Protection Nurses Network, NHS Health Scotland and the Leith Agency. The packs for schools and nurseries were issued in September 2007.
The campaign in the healthcare setting was supported through the introduction of Hand Hygiene Local Health Board Co-ordinators who continue to play a key role in implementing and monitoring hand hygiene standards at Health Board level, and who receive support funding from the HAI Task Force budget. Their input helped to increase hand hygiene compliance amongst healthcare workers from 68% compliance in February 2007 to 79% in September of that year.
Surveillance and NHS Scotland National HAI Prevalence Survey
The HAI Task Force has from the outset worked closely with HPS on a variety of surveillance programmes relating to HAIs. During the first phase of work mandatory surveillance programmes was continued for MRSA blood infections and introduced for Surgical Site Infections. In addition to these, voluntary surveillance programmes were developed in areas such as catheter associated urinary tract infection and HAIs in intensive care units. In particular, HPS were invited by the HAI Task Force to undertake a national HAI prevalence study to provide baseline information on the total prevalence of HAI in Scottish hospitals.
The results of the study were published on 11 July 2007. The study has been recognised as being one of the most comprehensive and detailed surveys of its kind in the world. It found a prevalence of 9.5% of healthcare associated infections in acute hospitals in Scotland, and provided a rich source of key baseline data on which to base future work.
MRSA
The HAI Task Force is committed to the reduction of all healthcare associated infections. Some infections such as MRSA and Clostridium difficile provoke a high level of public concern and specific measures have been drawn up by the HAI Task Force to help tackle them. The first action plan initiated the development of a National MRSA Control Strategy, which is due to be published in summer 2008. In addition, the Task Force invited NHS Quality Improvement Scotland ( NHSQIS) to undertake a health technology assessment ( HTA) on the clinical and cost effectiveness of screening for MRSA.
The importance of MRSA was further emphasised over the course of the second programme with the introduction of a Health Efficiency Access Treatment target to reduce the level of all Staphylococcus aureus blood infections, including MRSA by 30% by 2010. The second phase of work saw the publication of the MRSAHTA which concluded that universal screening for all hospital admissions was the most effective and cost efficient method. The Scottish Government acted on these recommendations and announced in March 2008 that a pilot screening programme would be implemented in NHS Ayrshire and Arran, NHS Grampian and NHS Western Isles in 2008/2009.
Clostridium difficile (C.diff)
Rising concerns about Clostridium difficile saw a mandatory surveillance programme introduced during the second phase of the HAI Task Force work programme. This was alongside work to specifically target C. diff, such as a dedicated care bundle. In addition, HPS have introduced new reporting of validated Clostridium difficile data which now gives the HAI Task Force an accurate starting point from which to develop a national approach towards reducing C. diff infections. To help speed up treatment for patients a Clostridium difficile reference laboratory has been established in Scotland so that samples no longer have to be sent to the laboratory in Wales.
Patient Safety
The HAI Task Force set up a working group to develop a risk based methodology to set priorities for targeting measures to reduce the risk of HAI. This continued into the second phase and lead to the publication of an interim guidance document The Risk Management of HAI: A Methodology for NHSScotland. The second Delivery Plan also saw additional measures to promote patient safety, in particular the introduction of healthcare associated infection related 'Care Bundles' - an internationally recognised way of reducing risk and improving safety when delivering care.
Patient safety is a fast developing area in NHS Scotland. In particular, the launch of the Scottish Patient Safety Programme, co-ordinated by NHS Quality Improvement Scotland ,ensures that this is an area which remains at the top of the NHS agenda. The HAI Task Force will continue to forge links between the Patient Safety and Patient Experience programmes and the HAI agenda to ensure there is a coherence of approach in the way that NHSScotland delivers its service to patients. In addition, the HAI Task Force will revise the publication The Risk Management of HAI: A Methodology for NHSScotland to ensure that it fits with both agendas.
Research
The HAI Task Force recognises the importance of high quality research in effectively tackling HAI. During the first phase of work an HAI Research Workshop was conducted, facilitated by the Chief Scientist's Office ( CSO) and NHS Education for Scotland. Following this, NHSNES issued guidance on preparing HAI related research proposals for the CSO and an informal Scottish HAI Research Network was established to ensure that HAI research proposals fulfilled the CSO's quality requirements.
During the second phase of work the recommendation to establish the existing Network on a more formal basis was agreed. Based at the University of Glasgow's Faculty of Biomedical and Life Sciences, the Scottish Infection Research Network ( SIRN) comprises a formal Steering Group and an informal Network to work towards increasing the quality of research, and contribute towards the prevention and control of Healthcare-Associated Infections.
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