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Shetland NHS Board

Control of Infection Committee

Annual Report

April 2011 - March 2012

Prepared by Dr Susan Laidlaw, on behalf of Control of Infection Committee

June 2012

NHS Shetland Control of Infection Committee Annual Report 2011-2012

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Acronyms and Abbreviations

ARI Aberdeen Royal Infirmary

AOBD „acute occupied bed days‟

CDI Clostridium difficile infection

CDU Central Decontamination Unit

CGC Clinical Governance Committee

CHCP Community Health & Care Partnership

CoIC Control of Infection Committee

CRA Clinical risk assessment (for MRSA Screening)

CRBN Chemical, Radiological, Biological or Nuclear (Incident)

DATIX Software for patient safety, incident and risk reporting and management

DPH Director of Public Health

HAI Healthcare associated infection

HAI SCRIBE Healthcare Associated Infection System for Controlling Risk in the Built Environment

HDL Health Department Letter

HDU High Dependency Unit

HEAT targets Health, Efficiency, Access, Treatment Targets (Scottish Government)

HEIS Healthcare Environment Inspectorate Scotland (incorporated into HIS from April 2011)

HIS Health Improvement Scotland (new national scrutiny body from April 2011)

HPS Health Protection Scotland

ICM Infection Control Manager

ICT Infection Control Team

iiiP Infection Improvement and Implementation Programme

ISD Information Services Division, National Services Scotland

JAG Joint Advisory Group on Gastrointestinal Endoscopy

KPI Key Performance Indicator

LHBC Local Health Board Co-ordinator (Hand Hygiene Campaign)

NES NHS Education Scotland

MMR Combined measles, mumps and rubella vaccination

PFPI Patient Focus Public Involvement

PPE Personal Protective Equipment

PPF Public Participation Forum

MRSA Meticillin Resistant Staphylococcus aureus

MSSA Meticillin Sensitive Staphylococcus aureus

QIS Quality Improvement Scotland (superseded by HIS from April 2011)

SAB Staphylococcus aureus Bacteraemia

SPSP Scottish Patient Safety Programme

SSHAIP Scottish Surveillance of Healthcare Associated Infection Programme

SSIS Surgical Site Infection Surveillance

TOBD „total occupied bed days‟


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Contents

1 Introduction 3

1.1 Remit of Control of Infection Committee 3

1.2 Accountability 4

2 Background to Work Programme 6

2.1 HAI Taskforce Delivery Plan 6 2.2 HAI Action Plan (in response to Vale of Leven C diff outbreak) 6 2.3 The QIS Standards and Healthcare Environment Inspectorate Scotland (HEIS) Inspection 6

2.4 National MRSA Screening Programme 7

3 Progress against Work Programme for 2011 – 2012 7

3.1 Surveillance 7 3.2 Training 11 3.3 Policy and Procedure Development 13

3.4 Prevention of Healthcare Associated Infection (HAI) 14 3.5 Patient Focus Public Involvement 19

3.6 Audit 19

4 Occupational Health 20

4.1 Prevention of occupational infection with blood borne viruses 20 4.2 Seasonal flu vaccination programme 20

4.3 Skin problems due to hand hygiene products 20

5 Communicable Disease Control 21

5.1 Vaccination & Immunisation Group 21

5.2 Emergency Planning 22

6 Significant Incidents 23

6.1 Communicable disease incidents 23

6.2 Incidents of potential infection risk 24

7 References 25

Appendices

Appendix A: Communicable Disease & Infection Control Surveillance Report 2011-12

Appendix B: Work Programme for 2012-2013


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1 Introduction

Infection control covers a wide range of activities. These range from preventing patients picking up infections when they come into hospital, to controlling outbreaks of infectious diseases, such as food poisoning, in the community. Although much activity is co-ordinated by the Infection Control Team (ICT) led by the Infection Control Manager many others are involved in infection control activities. These include NHS clinical staff, cleaning staff and the Estates Department and the Shetland Islands Council‟s Environmental Health Department.

The Control of Infection Committee (CoIC) acts as the central committee to oversee all infection control issues within Shetland NHS Board. The constitution of the Committee was revised in 2009 to bring it up to date with new roles and responsibilities within the Board and again in 2011 to reflect further changes, and the membership and remit of the Infection Control Team was similarly reviewed.

During 2011 a new post of Consultant Microbiologist was created and Dr Adam Brown was appointed to this post. Within this post Dr Brown has a remit as Infection Control Manager and Infection Control Doctor.

1.1 Remit of Control of Infection Committee

To review and provide advice on Shetland wide infection control strategies and policies within the service

To facilitate collaboration and co-ordination between different health service sectors, Shetland Islands Council and other agencies and to liaise with neighbouring NHS Board Control of Infection Committees

To provide advice and support to the ICT and to assist the Director of Public Health in providing advice to hospital and community services

To endorse the annual infection control programme prepared by the ICT

To prepare an annual report for the Board, presented through risk management and clinical governance channels to the Clinical Governance Committee


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1.2 Accountability

The Control of Infection Committee reports regularly (and also in the event of a significant incident or outbreak) via the Clinical Governance Coordinating Group (CGCG) and Health and Safety Committee to the Clinical Governance Committee (CGC). The Clinical Governance Committee is the Board appointed Committee for health and safety and clinical governance matters in NHS Shetland. The Control of Infection Committee receives reports from the Control of Infection Team, and also a direct report in the event of a significant incident relating to infection control, or outbreak.

Executive lead input

Director of Nursing, Midwifery and Allied Health professionals

(Executive Lead for HAI)

Director of Public Health (Executive Lead for

Communicable Disease Control and Emergency

Planning)

Vacc & Imm Group

Shetland NHS Board

Clinical Governance Committee

(Risk Management)

Clinical Governance

Co-ordinating Group

Health & Safety Committee

Control of Infection

Committee

Cleanliness Champions

Infection Control Team

Annual Report

Antimicrobial Management

Team

Area Drug and Therapeutics Committee

Reporting route

Minutes shared


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1.3 Committee membership April 2011 – March 2012

(* Member of Infection Control Team )

Director of Public Health Dr Sarah Taylor*

HAI Executive Lead Kathleen Carolan*

Infection Control Manager / Consultant Microbiologist / Infection Control Doctor

Dr Adam Brown* from May 2011

Infection Control Nurse (Hospital) Tina Bokor-Ingram*

Public Health Nurse Wendy Hatrick*

Lay Representative Currently vacant

CHCP representative / Asst. Director of Nursing (Community)

Edna Mary Watson*

Asst. Director of Nursing (Hospital) Janice McMahon*

Consultant Microbiologist (Aberdeen) Dr Annemarie Karcher to May 2011

Head of Estates John McBeath*

Laboratory service rep Julie Sims

Occupational Health Nurse Bernadette Dunne*

Pharmacy Manager David Anderson

Medical Director or rep Dr Jim Unsworth to August 2011

Dr Roger Diggle from December 2011

Cleanliness Champion rep Edna Peterson

Sodexho Hotel Services Manager or rep Ailsa Clews to November 2011

Valery Lafferty from November 2011

SIC Environmental Health Services Manager Maggie Dunne

Facilities Manager Magnus Flaws

Consultant in Public Health

(Deputy for DPH)

Dr Susan Laidlaw*


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2 Background to Work Programme

The work programme covers a number of areas concerned with infection control both in health care settings and the community. These include:

surveillance

training

policy and procedure development

prevention and management of healthcare associated infection

audit

As in previous years, most of the work programme for 2011 - 2012 was based on developing and implementing local action plans concerned with the prevention and management of healthcare associated infection (HAI), a national priority for the Scottish Government and for the Board. These action plans have been produced in response to the following national initiatives:

2.1 HAI Taskforce Delivery Plan

In 2003, the Scottish Executive Healthcare Associated Infection Taskforce was set up in response to the Ministerial Action Plan „Preventing infections acquired while receiving healthcare‟.1 The Taskforce produced a programme of work which aimed to co-ordinate and build on existing HAI activities across healthcare settings in Scotland, based on the message: 'clean healthcare environments, clean hands, clean instruments'. In 2006 the Taskforce published a Delivery Plan for 2006-2008, which included further work on the areas listed above, along with new initiatives such as the National Hand Hygiene Campaign. A third Delivery Plan was introduced in 2008 for 2008-2011.2 A number of the programmes of work have been embedded into routine practice including hand hygiene audits.

2.2 HAI Action Plan (in response to Vale of Leven C diff outbreak)

In 2008 there was an outbreak of Clostridium difficile at the Vale of Leven Hospital in NHS Greater Glasgow and Clyde. 55 patients developed Clostridium difficile infection (CDI) and 18 died. As a result of this there was an Independent Review and a number of issues were identified that had contributed to the problems at Vale of Leven. The Scottish Government subsequently produced a HAI Action Plan to address these issues and ensure good infection prevention and control procedures are in place across all NHS Boards.

2.3 The QIS Standards and Healthcare Environment Inspectorate Scotland (HEIS) Inspection

In March 2008 QIS (Quality Improvement Scotland, now Healthcare Improvement Scotland, HIS) published new HAI Standards for local assessment, These standards focus on compliance; patient focus and public involvement; prevention and control of infection; environment and equipment; and education. The aim was to build on the


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previous HAI standards, which focussed on structure and processes, and now to focus on outcome measures that will demonstrate improved Board performance. They recognise the importance of the NHS Scotland Code of Practice for the Local Management of Hygiene and HAI in the development of these standards, to build on work already implemented by the service. All NHS Boards were required to complete a self-assessment against the QIS Standards by June 2009 in preparation for the Healthcare Environment Inspectorate Scotland inspection visit. The HEIS made its first inspection visit to Gilbert Bain Hospital, NHS Shetland in December 2009; this was an announced visit. The inspection team examined NHS Shetland‟s self-assessment information and then inspected the hospital to validate this information, meet patients and staff, and visit wards and departments. During the visit, the inspection team also assessed the hospital‟s physical environment for issues related to healthcare associated infection. The findings from the visit set out five that NHS Shetland is fully expected to address, plus seven recommendations for improvement. It was anticipated that the HEIS would make an unannounced visit during 2011-12, but that has not yet happened.

The full HEI inspection report and an improvement action plan developed by NHS Shetland to address the identified issues are available to view at http://www.nhsqis.org/nhsqis/7111.html. The action plan was largely completed by March 2010, but a small number of outstanding actions, and ongoing development, were included in the 2010 – 11 Work Plan, and one action remained in 2011-12 (replacement of sinks).

2.4 National MRSA Screening Programme

This programme was introduced in January 2010 and initially involved nasal swabbing of all patients admitted electively to hospital (during their pre-admission assessment) and those admitted to Ronas Ward. This was in addition to the processes already in place in Shetland to screen patients locally assessed as being at higher risk of MRSA (patients transferred from mainland hospitals and those who had been MRSA positive in the past.) During 2011 the programme changed to two stage process: clinical risk assessment (CRA) of all patients admitted to hospital for at least one night and two site swabbing (nasal and perineal sites). The clinical risk assessment identifies patients deemed to be at higher risk of MRSA (based on the results of the pathfinder pilot MRSA screening project). 3 These include patients admitted or transferred from anywhere other than home (ie hospitals and residential homes); those who have indwelling devices and those who have been MRSA positive in the past. The new MRSA programme was due to be implemented across all NHS Scotland hospitals by end of March 2012. The implementation of the programme is to be monitored through audit against a set of Key Performance Indicators (KPIs), starting in 2012/13.

3 Progress against Work Programme for 2011 – 2012

3.1 Surveillance

Surveillance is the collection and analysis of information about cases of illness, for example infectious diseases. It is used to understand patterns of illness, particularly to

http://www.nhsqis.org/nhsqis/7111.html


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pick up where there is an unexpected increase in the number of cases of a disease. Surveillance is the responsibility of the Public Health Department in NHS Shetland.

The Infection Control Team receives monthly surveillance reports to oversee action taken in response to cases or trends in infection. The Control of Infection Committee receives regular surveillance reports on MRSA; Staphylococcus aureus bacteraemias; Clostridium difficile; Surgical Site Infection Surveillance; sharps injuries amongst NHS staff, notifiable diseases and vaccination uptake rates.

The Annual Surveillance Report 2011-12 (Appendix A) contains further details of the items summarised below.

3.1.1 MRSA (Meticillin Resistant Staphylococcus Aureus)

MRSA is a bacteria carried by many people that can sometimes cause serious infections, particularly in hospital patients. MRSA is identified in two ways:

Screening of patients (now as part of the National MRSA Screening Programme)

Isolating MRSA as a cause of infection (for example a wound swab or urine test)

During 2011-12, local surveillance figures show that there were 10 caused by MRSA, including chest, skin, wound and urinary tract infections. There were also 2 patients identified as being colonised with MRSA through screening. There were no MRSA bacteraemias.

3.1.2 Staphylococcus aureus bacteraemia (SAB) Nationally, both meticillin sensitive (MSSA) and meticillin resistant (MRSA) staphylococcus aureus bacteraemias are monitored and reported. The national system reports cases of bacteraemia with control limits designed to show where variations in rates might be significant. Staphylococcus aureus bacteraemia data have been monitored in Scotland since 2001 and there have been substantial reductions in these infections since this time. MRSA bacteraemias have reduced significantly over the last four years in NHSScotland. The incidence of MSSA bacteraemias has also reduced. The most recent national report was a national HAI annual report published in April 2012 which included cumulative data upto December 2011.4 This showed no SABs in Shetland since the second quarter of 2009. However local figures show there were two SABs during the last quarter of 2011 / 2012. These two SABs were both caused by MSSA. One was found to be due to a contaminated blood culture; this was therefore not a true bacteraemia, but will be included in the next set of national figures that are published. Preliminary investigation of the second case has shown that this may also be a contaminated sample. There is currently work ongoing locally to look at the issue of contaminated samples and what can be done to prevent them.

The small number of episodes reported from Shetland over recent years mean that these numbers should be interpreted with due caution.


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A HEAT target was introduced for all Boards to reduce all Staphylococcus aureus bacteraemias by 30% by March 2010. The baseline for Shetland was one per quarter (or four per year) so the target was one case per year. As reported above, the number of cases reported in Shetland is low, and very small variations in numbers – one or two cases, can change the rate disproportionately. Progress towards the target is monitored quarterly but using a rolling annual total. By March 2012, the rolling average in Shetland (using local figures) was 0.2 per 1000 acute occupied bed days, ahead of the trajectory of 0.32 and a target of 0.26 by end March 2013.

3.1.3 Clostridium difficile

Clostridium difficile is a bacterium, widely distributed in the environment and in the gastrointestinal tract of animals and also humans. Clostridium difficile infection (CDI) is a major cause of illness and death, especially as a healthcare associated infection. It usually follows use of antibiotics, with some antibiotics being more likely to trigger infection than others. Disease ranges from mild self-limiting diarrhoea to severe diarrhoea, pseudomembranous colitis, toxic megacolon and potentially death. In recent years, the numbers of infections caused by Clostridium difficile have increased and become more severe.

In Scotland, mandatory surveillance of CDI was introduced in 2006 as a result of this changing picture. The surveillance programme was initially set up to record the incidence of CDI in patients aged 65 and over. In April 2009, the programme was expanded to include the age group 15-64. Cases are identified through laboratory reports.

National cumulative figures upto December 2011 were published in April 2012 in the national HAI Annual Report.4 These showed that there had been no cases of CDI in Shetland for the past two years, since March 2009. However, local surveillance showed that there had been one case locally in October 2011. Although clinically this was a case of community acquired CDI, the initial positive lab result was not confirmed and so this had not been included in the national figures. A HEAT target for CDI was introduced in 2010/11: to reduce CDIs to 0.2 per 1000 total occupied bed days. The rolling rate for NHS Shetland (using our local data) was 0.07 by end March 2012.

3.1.4 Surgical Site Infection Surveillance (SSIS) Surgical site infections (SSIs) are an important cause of healthcare associated infections. They account for 15.9% of all HAI, and cost the NHS in Scotland £30 million per year.11

SSIs have serious consequences for patients affected as they have been estimated to at least double the length of hospital stay and also result in pain, suffering and possible further surgery. SSI is an important outcome measure for surgical procedures and the key aim of SSI surveillance is to improve the quality of patient care and to provide participating hospitals with robust SSI rates in order for them to compare with similar hospitals against benchmark rates. Evidence suggests that actively feeding back data to clinicians contributes to reductions in rates of infection. The Scottish Surveillance of HAI Programme (SSHAIP) within Health Protection Scotland (HPS) coordinates the SSI surveillance programme that is mandatory in all NHS Boards


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in Scotland. All NHS Boards are required to undertake surveillance for hip arthroplasty (for fractured hip) and caesarean section procedures as per the mandatory requirements of HDL (2006) 384 and CEL (11) 2009. 5 Patients who have had hip arthroplasty are followed up to 30 days postoperatively if the patient remains in hospital, or is re-admitted within this period. Patients discharged home before the 30 days are followed up until the point of discharge. Patients who have had a Caesarian section are followed up until 10 days postoperatively, whether or not they have been discharged.

The local data shows that we have a small number of procedures and a small number of infections, with no significant trends to date (see Appendix A).

3.1.5 Communicable disease surveillance

The Public Health Department is informed of cases of notifiable disease, both those suspected on clinical grounds, which are notified by the GP or a hospital doctor and those confirmed by the laboratory. This information is forwarded to Health Protection Scotland, which produces weekly updates on a national basis.

In January 2010 the list of notifiable diseases and the methods for reporting them to Public Health changed as a result of the new Public Health Act for Scotland.6 Some common infections have been removed from the list, including chickenpox and clinical suspicion of food poisoning (gastro-intestinal infection). Confirmed cases of salmonella, campylobacter and other gastro-intestinal infections are reported by the laboratory.

Appendix A shows these figures in detail for 2011-12, along with commentary on some of the specific infections reported. Of note this year, were three confirmed cases of pertussis. These were three children within one family who had not been vaccinated as part of the national childhood immunisation programme. There has been an increase in the number of cases of pertussis in Scotland, mainly amongst unvaccinated and partially vaccinated individuals, including those too young to be fully vaccinated. This has led to an enhanced surveillance programme commencing at the beginning of 2012/13.

There were also two cases of pulmonary TB during 2011/12. One was a worker from a Spanish fishing vessel and the other was a resident in Shetland. These cases are described in section 6: Significant Incidents.

3.1.6 Vaccination uptake rates

Childhood immunisations are managed and monitored through a local Vaccination & Immunisation Group, which reports to the Control of Infection Committee. National uptake figures, broken down by NHS Board and CHP, are reported on a quarterly basis by National Services Scotland Information and Statistics Division (ISD). The Vaccination & Immunisation Group uses these reports to monitor trends and take action if necessary. The Immunisation Co-ordinator also receives uptake figures broken down by GP practice and feeds these back to individual practices.

Details of uptake are included in Appendix A. Of note is the continued low uptake of MMR, although there is a gradual trend to children receiving their first MMR earlier and the uptake rates are slowly improving. There is also a relatively low rate of uptake of the


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pre-school booster by age of school entry which is to be addressed through the Vacc & Imm Group and individual practices. The uptake of flu vaccine rose a little this year, but fell a very slightly short of the target of 75% for people aged 65 and over, at 74.9%

3.1.7 Sharps injury

A sharps or contamination injury is when someone receives a puncture wound from a needle or other sharp instrument or object which could be contaminated and which may lead to infection. Also a person could come into contact with blood or body fluid that is blood stained through splashes in the eyes, mouth or broken skin or through a bite from a person. Although rare, there is the risk of contracting a blood borne infection such as HIV, Hepatitis B or Hepatitis C through a sharps or contamination injury.

Across Scotland the annual incidence of sharps injury is approximately 15 per 1,000 staff.7 Approximately 700 staff work within NHS Shetland and there were 13 recorded sharps injuries during 2011-12, which gives us a rate of 18.6 (in 2010/11 there were 17 injuries, giving an approximate rate of 24.3/1,000). The local rate has remained fairly constant in recent years. It is slightly higher than the national average, but this may be due to high levels of reporting and the effect of small numbers. The Occupational Health department continues to play a significant role in both raising awareness and training, and in responding to incidents – see section 4.1 below.

3.2 Training

3.2.1 Induction & refresher days for all NHS staff

The corporate induction day now in its eighth year has continually developed and continues to be delivered to all staff, except the junior doctors and student nurses, as both of these groups have their own specific induction. The induction day, which is delivered on the first working Monday of every month, has a number of specific sessions, delivered by experts, that the Board has decided are essential for all new staff to be made aware of and control of infection is such a topic. The Infection Control 15 minute session is always delivered by a member of the Infection Control Team which indicates the importance to the new members of staff of infection control. Between April 2011 and March 2012, 71 new members of staff attended the induction session.

Mandatory Refresher Training also runs every month and it is expected that every staff member, including bank staff, attend this course in an 18 month cycle. The course is reviewed and revised every 18 months and in this cycle there are a number of areas where infection control training is delivered. Firstly this day is split into two distinct parts; a morning where sessions are delivered in either presentation or practical session. The second part is for delegates to complete some Learn Pro e-learning modules.

There is a practical session on infection control, which can be varied according to the needs of the staff attending, but generally involves an update on current issues and new procedures. Again this session is always delivered by a member of the Infection Control Team. Evaluation of this session is consistently good. Between April 2011 and March 2012, 171delegates completed this training. One of the Learn Pro modules that delegates are required to complete is on Health Care Associated Infection. So far 179 staff have


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completed this training – including both clinical and non-clinical staff. There is an additional module for clinical staff on food hygiene: 148 have completed this module.

The student nurse induction has been updated and now includes a more comprehensive session on control of infection. This involves hand washing techniques and the proper use of gel dispensers. During the period of this report 62 pre- registration nursing students have undergone induction. Induction materials are reviewed to ensure currency.

Mandatory induction standards and codes of conduct were introduced for all Health Care Support Workers (HCSW) in January 2011. This incorporates a work book in which all newly appointed HCSWs must demonstrate their understanding of how they maintain a safe workplace for themselves and others. Standard 2 includes a focus on prevention and control of infection.

A cohort of HCSW is currently undertaking SVQ 3 in Care. In preparation for this programme 12 candidates undertook a development programme that included a focus on infection control and hand hygiene. There was an expectation that all candidates would undertake the Cleanliness Champions programme.

3.2.2 Decontamination: Central Decontamination Unit (CDU) staff:

One member of staff has completed the NVQ in Decontamination at level 3. This qualification has not been replaced by a technical certificate which involves completion of a workbook and an examination at the end of training. An update should be received shortly as to how this can be delivered in a remote and rural setting as travel costs are currently prohibitive. All mandatory organisational training has been completed by all staff in the department. All CDU staff have a eKSF PDP in place and have had a KSF development review.

3.2.3 Clinical skills training

A number of programmes are offered to staff via the Staff Development Course bulletin. Principles of prevention and control of infection underpin these programmes and are related specifically to the skill being taught.

3.2.4 Contamination Incident/ Needle Stick Injury Training

This course is for nursing, dental and medical Staff who are involved in the management of employees. It is aimed to educate about their role and responsibilities when a contamination incident/needle stick injury occurs. Four courses were run during 2011/12.

3.2.5 Cleanliness Champions (NHS Education Scotland package)

The most recent statistics supplied by NHS Education for Scotland (NES) indicate that 145 staff had completed the cleanliness champion programme by the end of March 2012, and nine staff were in progress. Staff have been supported to complete the programme by a number of means, for instance, protected time to complete the online programme with sessions held in the Staff Development Section. NES offer a range of online educational resources to support healthcare staff in the prevention and control of HAI and staff are encouraged to access these as appropriate.


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3.2.6 Food handling training for ward staff

There is a module on the Learn Pro package that all clinical staff must complete on food hygiene, during 2011-12, 148 staff members have completed this module.

3.2.7 Other training:

Accident and Emergency Decontamination Training

Accident and Emergency staff are responsible for the decontamination of patients in the event of a chemical, radiological, biological or nuclear (CRBN) incident and regular training and exercises are run to train staff in the use of the decontamination equipment. Training for 2011/12 was held in April 2012 and a local exercise to test the response is being planned for autumn 2012.

Staff Development Bulletin

There is an “Infection Control” section in the Staff Development Bulletin (published quarterly), which highlights key issues and training opportunities for all staff. It also contains a list of useful websites so that staff can access infection control information and training electronically and at a time that suits. The bulletin specifically highlights the NES on-line short courses that are available.

3.2.8 Infection Control Team: individual training programmes

Members of the Infection Control Team have also undertaken specific training within their Personal Development Plans. This includes the Infection Control Nurse currently undertaking a MSc in Advanced Practice (Infection; Diseases Prevention and Control) and a Specialist Practitioner Qualification; and other members of the team have completed training in HAI Surveillance and Incident Management.

3.3 Policy and Procedure Development

The following new policies, procedures and plans were approved by the Control of Infection Committee during 2011 – 2012

Mattress Policy (also approved by Clinical Governance Committee)

Anti-microbial Policy (also approved by Clinical Governance Committee)

The following policies and procedures were reviewed and updated during 2011/12

Safe Disposal of Healthcare (Clinical) Waste Policy (approved by CoIC and CGC)

Procedure for management of Clostridium Difficile (approved by ICT )

Procedure for the Management of MRSA (approved by ICT )

Policy for staff screening in the event of an outbreak (approved by CoIC)

Standard Infection Control Procedures: (approved by ICT)

Personal Protective Equipment


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Hand Hygiene

Patient Placement procedures

Environmental cleaning

Care of Equipment

Cleaning of isolation rooms

Linen procedures

Management of Spillages

Curtain cleaning

The reviews of the following documents are due to be completed in early 2012/13:

(Overarching) Infection Control Policy

Procedures for the prevention and management of Tuberculosis (TB)

Hospital Outbreak Plan

Pandemic Flu Plan

3.4 Prevention of Healthcare Associated Infection (HAI)

3.4.1 Decontamination

The Central Decontamination Unit (CDU) at the Gilbert Bain Hospital provides a decontamination service to ward areas and departments for NHS Shetland. The Glennie Report recommended that all decontamination (of surgical instruments and medical devices) should be carried out within a central processing unit. 6

The centralisation of the dental workload continues, with services from St.Olaf Street being the most recent to be absorbed by CDU. The workload of dental services at Montfield is currently being assessed with a proposal to centralise the workload by December 2012.

A dental business case has been approved by the Board for an upgrade of LDU facilities at Brae to achieve compliance with the national decontamination standards. A working group is currently appraising how best to achieve compliance for the decontamination of dental instruments for the Yell practice. The national Primary Care Working Group is informed of progress by NHS Shetland towards meeting the deadlines for Primary Care Compliance in Decontamination at national quarterly meetings. The deadline for this remains December 2012.

There is also now a national Endoscopy Working Group to assess progress on meeting national decontamination standards in Endoscopy. The project has two phased timescales in place. NHS Shetland has made good progress in this area with a very good report in relation to decontamination from the pre-JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation visit in August 2010 and the telephone review completed in 2011. All Stage One requirements have already been achieved.

The CDU is scheduled to be re-audited for re-certification to ISO 13485:2003 and the Medical Device Directive by SGS (Inspection Verification Testing and Certification Company) in Jul 2012.


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3.4.2 Task Force Delivery Plan

Cleanliness Champions

The local Cleanliness Champions continue to take forward the programme of local work on the prevention of HAI, with a particular focus on hand hygiene. There is a Board requirement that all qualified nurses and allied health professionals undertake the Cleanliness Champion training, but all staff are encouraged to consider doing the course. A total of 145 staff have now completed the course, with nine currently working on it (March 2012). The process for undertaking the course has changed, so that it all has to be done on line, and there has been a drive to encourage those that have been working on the course for a long period of time to complete. The Cleanliness Champions meet regularly and a Cleanliness Champion representative is a member of the Control of Infection Committee.

Hospital cleaning

During 2011/12 , the hospital cleaning continued to be carried out by our facilities management contractor Sodexo Healthcare; however from April 2012 the cleaning was due to be brought back in house, with most of the Sodexo employees moving over to NHS Shetland.

The cleaning methods and quality standards are set out in the NHS Scotland National Cleaning Services Specification. Cleaning standards were monitored on a regular basis both by Sodexo through their quality control system, and by NHS Shetland using the NHS Scotland cleaning monitoring tool. This latter system gives a numerical score with an overall target level of 90%. We have consistently exceeded the 90% target throughout 2011 – 2012, with only two occasions where the compliance has fallen below 90% within individual areas. Generally the overall figures for the each month have exceeded 95%.

A representative from Sodexo was included as a member of the Control of Infection Committee and the Board‟s Facilities Manager reported regularly on cleaning monitoring information.

Hand Hygiene Campaign

Since April 2007, NHS Shetland has participated in the national hand hygiene campaign, with the appointment of a Local Health Board Co-Coordinator (LHBC) who has led awareness and training, and conducted the local audits on hand hygiene within the national programme. These have been reported regularly into the Control of Infection Committee. The LHBC role is now covered by the Infection Control Nurse.

Figures for 2011 and 2012 are shown in Appendix A and remain consistently high. The audit focuses on compliance with hand washing through observations of hand hygiene opportunities and technique. Testing the knowledge of staff is done through the Infection Control Environmental Audit asking key questions about hand hygiene procedures.

During hand hygiene audits anyone demonstrating non-compliance is given verbal feedback immediately and given written materials such as leaflet or pocket credit card sized reminders. Hand Hygiene is a major focus of Induction and Mandatory Training for all staff. Additional Hand Hygiene Training has been provided in clinical areas as


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required. Basic Hand Hygiene Training was also given to outside contractors carrying out building works within Gilbert Bain Hospital and health centres during 2011-12

Action to achieve HEAT target: to reduce Staphylococcus Aureus bacteraemias

MRSA infection surveillance and management

In Shetland, the Public Health Department collects information on colonisation and all infections caused by MRSA and report these to the Infection Control Team and Control of Infection Committee. We also take part in the national surveillance system for MRSA (and MSSA) bacteraemias. When the Public Health Department receives a positive laboratory report, the referring ward or GP is asked to complete a local MRSA surveillance form. This allows for an investigation of the circumstances surrounding each case of infection, and identification of anything that could have been done differently to prevent the infection.

Scottish Patient Safety programme

NHS Scotland was the first health service in the world to adopt a national approach to improving patient safety. The Scottish Patient Safety Programme is co-ordinated by Health Improvement Scotland (HIS) and aims to steadily improve the safety of hospital care right across the country. This is being achieved using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and practice. As part of the Critical Care Workstream we continue to monitor the Central Line Insertion Bundle, Central Venous Catheter (CVC) Maintenance Bundle and the Peripheral Vascular Catheter (PVC) Bundle in the High Dependency Unit (HDU). The consultant anaesthetists ensure that details are updated on Wardwatcher (a national database system) and ward staff ensure that both CVC and PVC bundle compliance stickers are attached to patients notes. The current outcomes identify days between infections. As measured on 31st March 2012, the number of days since the last Central Line Bloodstream Infectionwas 1320 Days; the days since the last Staph. Aureus Bacteraemia (SAB) was 1195 Days and the number of days since a C. Difficile infection occurrence was 1195. Hand hygiene compliance is also audited in the unit.

The General Ward Workstream also includes outcome measures for SABs and C. Difficile disease occurrence: as measured on 31st March 2012, the number of days since last SAB (General Ward & other non-critical areas) was 27 days (as there was a SAB in March). The number of days since the last C. Difficile infection occurrence was 178. Hand Hygiene and the PVC Bundle process measures monitor compliance levels monthly as part of the programme.

SPSP improvement methodologies are being integrated in Infection Control through the Infection Improvement and Implementation Programme (iiiP). The alignment of these two programmes aims to ensure that everything done has a measurable, lasting effect on safety and quality in healthcare in terms of infection prevention and control.

MRSA Screening Programme

This programme was introduced in January 2010 and initially involved nasal swabbing of all patients admitted electively to hospital (during their pre-admission assessment) and those admitted to Ronas Ward. This was in addition to the processes already in place in


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Shetland to screen patients locally assessed as being at higher risk of MRSA (patients transferred from mainland hospitals and those who had been MRSA positive in the past.) During 2011 the programme changed to two stage process: clinical risk assessment (CRA) of all patients admitted to hospital for at least one night and two site swabbing (nasal and perineal sites). The clinical risk assessment identifies patients deemed to be at higher risk of MRSA (based on the results of the pathfinder pilot MRSA screening project).3 These include patients admitted or transferred from anywhere other than home (ie hospitals and residential homes); those who have indwelling devices and those who have been MRSA positive in the past. The new MRSA programme was due to be implemented across all NHS Scotland hospitals by end of March 2012. The implementation of the programme is to be monitored through audit against a set of Key Performance Indicators (KPIs), starting in 2012/13.

The implementation process started with moving over to two site swabbing for screening purposes in all areas. The pre-operative assessment clinic implemented the CRA by September 2011 and the wards began implementing CRA towards the end of 2011/12.

3.4.3 Prevention Of HAI: HAI Action Plan (Vale Of Leven)

Actions from this Action Plan have been fully implemented, including continuing bi-monthly reporting on HAI to the Board.

3.4.4 Integrated HAI Action plan

During 2011/12 a number of areas of work from the Integrated Action Plan have continued :

A monthly report from the ICT for all clinical teams

Continued installation of clinical handwash basins

Inclusion of objectives related to HAI in the annual objectives for all staff at Band 7 and above.

Regular walk-arounds undertaken by senior managers

The quarterly Estates User Forum

An organisational lead from the Chief Executive, through the Senior Management Team, on expectations including prioritisation of HAI and tackling poor performance - demonstrated through team briefs; walk arounds; management of poor performance and zero tolerance.

3.4.5 Antimicrobial prescribing

The use of antimicrobials is important in the management of infections; but appropriate antimicrobial prescribing and management is a priority to reduce the risk of microbial resistance, and development of organisms such as MRSA. It is also a key factor in preventing C.difficile which is associated with certain antibiotics. A multi-disciplinary Antimicrobial Management Team, led by the Consultant Microbiologist, supports the management and monitoring of antimicrobial practice across NHS Shetland. The main focus was initially the hospital, but the remit of the team is now extending into primary care.


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A local Antimicrobial Policy was approved in May 2011 by the Clinical Governance Committee. This had been drawn up as a local response to the national guidance for safe, effective and appropriate antibiotic management and prescribing. A governance structure for antimicrobial prescribing to support the policy was also introduced, incorporating the role of the newly appointed Consultant Microbiologist and also the role of a pharmacist with an antimicrobial prescribing remit.

There is a regular audit of anti-microbial prescribing on wards 1 and 3 which is reported to the Infection Control Team and Control of Infection Committee. This audit looks at case notes of patients prescribed anti-microbials to monitor compliance with antimicrobial prescribing policy. Each week, five patients on antibiotics are sampled in medicine, and five in surgery, with a target of twenty patients in a month. The pharmacist confirms that the indication has been documented in the notes and, when it has, the antibiotic choice is compared to the local empirical guidance. If the choice, differs from local guidance, but the choice was made on the advice from microbiology, that is taken as compliant. These are converted to percentages and provided monthly on run charts.

3.4.6 Hospital Capital Plan and Estates maintenance work

All requests for Estates work, such as issues picked up during Environmental Audits, are now prioritised according to a risk score and there is a dedicated budget to deal with the highest risk actions.

A number of estates actions with an impact on infection control have been completed in 2011-12 through an action plan started in 2010. Work carried out has included the following projects.

Continued replacement of wash hand basins ( lower priority DSR replacement basins)

Replacement of Ward 1 skirting / flooring

Repairs to sink areas in Theatres

Upgrading of Theatres pipework

Replacement of soap / alcohol gel / handcream dispensers throughout NHS Shetland (due to manufacturer changing the products).

Work on St.Olaf St Dental Surgery

There has also been a considerable amount of work in improving the Waste Management processes, including a new system for disposal of waste and a process for cleaning wheelie bins at the SIC cleaning depot.

3.4.7 HAI prevalence Survey

During September and October 2011 the second national Point Prevalence Survey of healthcare associated infection and antimicrobial prescribing was undertaken. Members of the Infection Control Team were trained to do the audit for the Gilbert Bain Hospital. The National Report was published in April 2012 and showed that the prevalence of HAI in the Gilbert Bain Hospital on the day of the survey (involving 35 patients) was 8.6%, but with wide 95% confidence intervals (of 4.3 – 23.8%).8 This is similar to the prevalence at


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the time of the last survey. The overall prevalence in acute care hospitals across Scotland was 4.9% which is significantly lower than at the time of the first survey in 2006.

3.5 Patient Focus Public Involvement

Public involvement occurs at a number of levels throughout the Board‟s activity in relation to HAI. Public membership of the Infection Control Committee was first achieved in 2007 through a nomination made from the then public panel, NHS Shetland 100. In August 2010, the Public Partnership Forum (PPF) was launched. This group, which supersedes NHS Shetland 100, and the Patient Focus Public Involvement (PFPI) Steering Group have continued to actively participate in informing and directing HAI activity throughout the Board.

At PPF, a number of HAI items have been discussed over the last year including the implementation of the MRSA Screening Programme.

Over the last year, lay involvement within various hospital walk rounds has continued, including Environmental Cleaning and Hospital Cleanliness, with feedback being received at each PFPI Steering Group. This ensures that cleaning audits include a valued lay perspective which is quickly acted on.

There has been no lay representative on the Control of Infection Committee for a number of years, but a new representative has been identified to start in 2012/13.

3.6 Audit

Audit activity has been focussed on the implementation of new and revised infection control procedures. The following audits were conducted during 2011/12:

Blood Culture Audit

Mattress Audits

Waste Audit

Environmental Audits - incorporating fridge, green tape (clean equipment) and storage audits)

Monthly Hand Hygiene audits in every clinical area

Monthly Cleaning Specification audits in every clinical area

Antimicrobial prescribing audits

The Infection Control Environmental Audit has continued this year, with every clinical area being audited on a regular basis, based on performance, with lower scaring areas being audited more frequently to check that identified actions have been implemented.

The blood culture audit showed that there were issues with contaminated culture samples which is being further investigated and acted upon; which may include training and implementation of procedures .


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4 Occupational Health

The Occupational Health Department now has a full complement of staff and has been actively contributing to the work of the Control of Infection Committee and Infection Control Team. The OH staff are particularly involved in management, monitoring and training regarding sharps injuries. They have also been involved in the development of local policies and procedures.

4.1 Prevention of occupational infection with blood borne viruses

Although rare, there is the risk of contracting a blood borne infection such as HIV, Hepatitis B or Hepatitis C through a sharps or contamination injury in the healthcare setting. The Occupational Health department continues to play a significant role in both raising awareness and training, and in responding to sharps incidents. Incidents are logged and clinical areas that have had more than one incident have seen reductions by targeting them with additional support. Efforts have continued over the last year to increase awareness and training on sharps and blood borne viruses with formal training sessions run by Occupational Health staff through the Staff Development Service. Before starting their post, new staff (including junior doctors on rotation) are given individual advice on sharps injury management.

As well as offering advice and support to staff members exposed to risks, the Occupational Health Department will monitor compliance with NHS Shetland‟s procedure for Protection against Occupational Infection with Blood Borne Viruses and feedback any need for further action. The local procedures for protection against occupational infection with blood borne viruses was reviewed during 2011.

4.2 Seasonal flu vaccination programme

Health and social care staff directly involved in patient care are recommended to have the seasonal flu vaccine. Some of the jobs and areas this covers include anyone who works in a GP practice, pharmacy, hospital, paediatric ward, cancer centre or those caring for patients with cancer, dental surgery or care homes. Not only will it reduce the risk of catching the flu but also will reduce the risks to those being cared for from catching the flu. The Shetland Occupational Health Department provides occupational health services to both NHS staff and other organisations including Shetland Islands Council. During the 2011-12 flu season, Occupational Health was proactive in offering clinical staff the flu vaccine, particularly in the higher risk areas of maternity and elderly care. 19.3% of all NHS Shetland staff received flu vaccination through Occupational Health (this compares to a previous uptake of around 10%). Uptake amongst clinical staff was 28.4%. Uptake in the higher risk areas of elderly care (Ronas Ward) and maternity was 41.7% and 61.9% respectively.

4.3 Skin problems due to hand hygiene products

Following the changeover of suppliers of hand hygiene products, soap, alcohol gel and moisturizing lotion in 2011, the Occupational Health team noticed an increase in the numbers of staff presenting with skin problems on their hands and the number of management referrals increased: from four management referrals between the 1st


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September 2010 until the 1st June 2011, to 12 management referrals in the same period this year ie 1st September 2011 to 1st June 2012. In the back ground to this there have been others who have had problems but have not been referred as they have managed to settle the symptoms themselves. The skin problems have mainly been resolved by changing soaps within the range, encouraging better use of emollient, and ultimately offering an alternate product for some. The plan is to reassess the numbers of staff who have been referred in July 2012 and if there remain a higher than expected number of referrals, the continued use of current products will be reviewed.

As part of the Health and Safety Executive National Inspection Programme: Preventing Dermatitis, there was a visit to the Gilbert Bain Hospital in August 2011. The report showed that as a Board we had good processes in place for preventing dermatitis.

5 Communicable Disease Control

The Public Health Department has an ongoing responsibility for communicable (infectious) disease control in the hospital and the community. The local Public Health Department has continued to deal with communicable diseases notified to the department; offering advice and instituting control measures where necessary, often in conjunction with Environmental Health. Staff have been involved in a range of activities including:

Direct contact with and liaison between patients, the public, NHS staff, environmental health and others

Dissemination of information including to patients, the public, NHS staff and the media

Further development of departmental systems for surveillance and management of communicable diseases and related issues using computerised recording of cases and incidents.

Delivery of training, both to NHS staff through the induction and refresher days and to other partner organisations on request.

Continued local implementation of the Public Health etc (Scotland) Act 2008.

5.1 Vaccination & Immunisation Group

The Board‟s Vaccination and Immunisation Group meets regularly and reports to the Control of Infection Committee on uptake rates, and on local actions to improve uptake and comply with national policy.

The following areas of work were covered during 2011-12:

Childhood immunisation programme, through Primary Care

Seasonal flu and pneumococcal programme, through Primary Care

HPV immunisation programme for teenage girls, through School Health

BCG programme for high risk individuals, through Child Health


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Hepatitis B vaccination for high risk individuals, through a range of services locally including the addictions services, the sexual health clinic, primary care and services in Grampian.

A local campaign to promote uptake of the first dose of MMR at the age of one year in 2011

A local campaign to promote uptake of the teenage booster and MMR amongst teenagers in 2012

Primary care teams also provide travel health advice and vaccinations to their patients and the Occupational health services provided the relevant vaccinations for health and other staff.

The Immunisation Co-ordinator has been actively involved in promoting the on-line Immunisation Training Package. During 2011/12 eight staff commenced the course: three completed the whole course, with a further two with just the practical element to do. This brought the total number of staff commencing the course to 29, with ten who have completed, 13 currently working on the course and 6 staff who have left NHS Shetland.

There was no local annual immunisation update training session held in 2011-12, but the next session is planned for May 2012.

Details of local surveillance and uptake figures are included in Appendix A.

5.2 Emergency Planning

The Director of Public Health (DPH) is a member of the Shetland Emergency Planning Forum. The Forum meets at least annually and considers all types of local emergency including incidents that may affect the health of the public such as infectious disease outbreaks and biochemical hazards. The DPH, along with the Assistant Director of Nursing (Hospital), is also a member of the Forum Executive, which meets quarterly.

Activity during 2011 -12 has included:

Managing the consequences of disruption to flights caused by volcanic ash in May 2011.

Preparation for the Tall Ships event in July 2011

Annual review of winter planning arrangements

A number of emergency planning exercises and training and training events were held throughout the year including the following which involved NHS Shetland staff:

Emergency Incident Training – Shore Line response (November 2011)

Emergency Incident Training – for the Senior Management Team (March 2012)

Exercise „Ready About‟ in April 2011. This was a tabletop exercise to test the contingency plans for the Tall Ships event.


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Exercise Sula in May 2011. This was a Maritime and Coastguard Agency run exercise regarding marine pollution and the shoreline response. Although input from NHS Shetland was offered, there was only minimal involvement required.

NHS Shetland tabletop exercise to test business continuity plans in November 2011

Exercise Bonxie 4 in November 2011. This was a continuation of the three year modulated exercise carried out at Sumburgh Airport by Highlands and Islands Airports Limited. This phase was the reception of casualties into the Gilbert Bain Hospital following an aircraft crash at Sumburgh Airport. There will be a fifth exercise during 2012/13 to test aftercare response.

An Emergency Planning Annual Report is produced annually and presented to Shetland NHS Board.

6 Significant Incidents

Significant incidents involving infection control matters are reported regularly to the Control of Infection Committee. Complaints would also be reported, but no complaints on communicable disease or infection control matters have been received during 2011/12.

6.1 Communicable disease incidents

April 2011 Legionella case A patient who worked in Shetland was admitted to the Gilbert Bain Hospital after becoming unwell and was subsequently transferred to Aberdeen where legionnaire‟s disease was confirmed. The patient was a resident of Lanarkshire and had also stayed in Aberdeen before becoming unwell. Potential sources of the infection were investigated, and there was no evidence that the infection had been caught in Shetland. During April and May there were more than the expected number of cases of Legionnaire‟s disease in Lanarkshire and Glasgow which prompted an outbreak investigation, but to date no common cause has been found.

June 2011 Single tuberculosis (TB) case A patient was admitted from a fishing boat to the Gilbert Bain Hospital with symptoms and signs suggestive of TB. He was well enough to be discharged and return home (abroad) and laboratory results subsequently confirmed smear negative respiratory TB. As the patient was smear negative and had not been coughing whilst an in-patient and on discharge, the risk of infection for other people that he had come into contact with was very low. However, as per usual procedures, it agreed to perform a contact tracing exercise to identify close contacts and offer appropriate screening. However this proved to be quite a lengthy process as the close contacts are all on the fishing boat which had left Shetland waters after the patient was admitted and then was out at sea, due to return to Spain at some point. All the crew were considered as close contacts because of the close living quarters. After liaison with the company agents in Scotland and Spain, and also involving port health in Cornwall, a letter was issued to the crew members and the manager / owners advising that the crew should be screened for TB. Feedback from the


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company was requested regarding the results of the screening, specifically if any further cases were found, but none were reported.

July 2011 Cryptosporidium in Drinking Water – Fair Isle Scottish Water‟s routine testing showed an increase in cryptosporidium in the drinking water, and as a precaution people living and staying on Fair Isle were advised to boil their drinking water from 30th July until the testing showed the cryptosporidium had cleared. Scottish Water also arranged bottled water for the island. The nurse on Fair Isle, NHS 24 and the Levenwick surgery were advised of the situation. Three clear water samples taken over the next four days and the boil water notice was lifted. There were no reports of any human cases of cryptosporidium during this incident.

The problem had arisen because Fair Isle usually sources drinking water from a bore hole, but at times of heavy use (this time it was due to tourists and extra visitors from the Tall Ships event) it is supplemented with burn water. Burn water sometimes gets contaminated with cryptosporidium particularly in times of heavy rain when animal faeces, usually from sheep, can contaminate the water. Very low levels are not uncommonly found in rural water supplies, but on this occasion the level found was high enough to warrant precautionary measures.

December 2011 Single tuberculosis case

A case of infectious TB was diagnosed in Shetland in December 2011 in a patient who had experienced symptoms including a cough since the end of October 2011. The immediate family (the spouse and two adult children) were notified and advised by the TB team in NHS Grampian, the patient being an inpatient in Aberdeen Royal Infirmary at the time. The case had contact with two Primary Schools in Shetland. In discussion with Public Health colleagues in Grampian, and in line with the TB Policy, it was agreed to wait for contact tracing until definitive typing of the organism to establish whether it had the potential for person to person spread. Both school headteachers and the Schools Service were advised of this.

In January 2012 the laboratory confirmed the case as Mycobacterium Tuberculosis with typing. Because of the small possibility that the affected person was mildly infectious before they were started on treatment, as a precautionary measure NHS Shetland offered screening to the children and relevant staff of the two schools involved. In total 35 individuals were identified as close contacts: of these four were referred to their GP for a chest x-ray; one required with no further action; and 28 were given a BCG (vaccination against TB) after a negative Mantoux (TB) test. Two further individuals who were living abroad were screened through a local clinic. No further cases of TB were found as a result of the screening.

6.2 Incidents of potential infection risk

October 2011 Flood in the Gilbert Bain Hospital.

This co-incided with a problem with the district heating system. Business Continuity Plans were implemented and the situation was managed resulting in no infection control risk.


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7 References 1 Scottish Executive. Preventing infections acquired while receiving healthcare: The Scottish Executive's

Action Plan to reduce the risk to patients, staff and visitors. Scottish Executive, 2002. Available at: www.scotland.gov.uk/Publications/2002/10/15677/12344

2 Scottish Government Healthcare Associated Infection Task Force: Delivery Plan April 2008.Scottish

Government; 2008. Available at: www.scotland.gov.uk/Publications/2008/03/07110818/0

3 www.hps.scot.nhs.uk/haiic/sshaip/mrsascreeningprogramme.aspx

4 www.documents.hps.scot.nhs.uk/hai/annual-report/annual-surveillance-hai-report-2011.pdf

5 Scottish Government Health Department. A revised framework for national surveillance of healthcare

associated infection and the introduction of a new health efficiency and access to treatment (HEAT) target for Clostridium difficile Associated Disease (CDAD) for NHS Scotland. NHS CEL(2009)11:SGHD;2009. Available at: www.sehd.scot.nhs.uk/mels/CEL2009_11.pdf

6 Public Health etc. (Scotland) Act 2008 available at: www.scotland.gov.uk/Topics/Health/NHS-

Scotland/publicact

7 Source: Information and Statistics Division of NHS National Services Scotland. Data available at the ISD

website Scottish Health Statistics (last updated October 2004): www.isdscotland.org/isd/new2.jsp?pContentID=3117&p_applic=CCC&p_service=Content.show&

8 Health Protection Scotland. Scottish National Point prevalence Survey of Healthcare Associated Infection

and Antimicrobial Prescribing 2011. Glasgow: Health Protection Scotland; 2012. Available at: www.documents.hps.scot.nhs.uk/hai/sshaip/prevalence/report-2012-04.pdf

http://www.scotland.gov.uk/Publications/2002/10/15677/12344

http://www.scotland.gov.uk/Publications/2008/03/07110818/0

http://www.hps.scot.nhs.uk/haiic/sshaip/mrsascreeningprogramme.aspx

http://www.documents.hps.scot.nhs.uk/hai/annual-report/annual-surveillance-hai-report-2011.pdf

http://www.sehd.scot.nhs.uk/mels/CEL2009_11.pdf

http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/publicact

http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/publicact

http://www.isdscotland.org/isd/new2.jsp?pContentID=3117&p_applic=CCC&p_service=Content.show&

http://www.documents.hps.scot.nhs.uk/hai/sshaip/prevalence/report-2012-04.pdf

control of infection committee annual report - nhs … · laboratory service rep julie sims ......

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