2. What has been achieved?
This section summarises the key components of the HAI Task Force Delivery Plan and highlights the outcomes achieved across priority areas between 2008 and 2011.
DELIVERY AREA 1: PATIENT SAFETY, PRACTICE AND CULTURE
Action area 1.1 Development of care bundles
1. Care bundles are a small set of practices - generally three to five - that, when performed collectively, reliably and continuously, have been proven to improve patient outcomes. Essentially, bundles contain the most important actions for patient safety for any given disease or negative outcome prevention programme.
2. HPS was commissioned by the HAI Task Force to take the lead in developing several care bundles, including:
- peripheral vascular catheter ( PVC) bundle;
- central vascular catheter ( CVC) bundle (and checklist);
- ventilator-associated pneumonia ( VAP) bundle;
- CDI cross-transmission prevention bundle;
- catheter-associated urinary tract infection ( CAUTI) bundle (and checklist); and
- SSI bundle. 5
3. All bundles were tested in a range of hospitals and are being progressively rolled out across NHS boards to improve the process of delivering care and to positively impact on patient outcomes. The bundles have been adopted by the Scottish Patient Safety Programme ( SPSP) where appropriate, and good evidence is emerging that the use of care bundles by NHS staff is having a positive effect in reducing avoidable HAIs.
4. Consideration of appropriate next steps in this area includes:
- developing greater understanding of what is driving HAIs locally and whether there are sufficient tools available to reduce incidence;
- identifying what tools are (and are not) being used in sufficient quantity to affect incidence within NHS boards;
- developing greater understanding of how the tools are been used locally and what is working in specific contexts; and
- specifying responsibility for ensuring local assessment and deployment of quality improvement tools.
5. A new group has been formed, led by HPS and NHSQIS, which will review existing tools to ensure they remain up to date and assess the need for additional tools to enable healthcare workers to optimise any system where there are risks of HAI.
Action area 1.2 Implementation of care bundles; Action area 1.3 Monitoring of compliance with implementation; Action area 1.4 Evaluation of care bundle approach
1. These three areas, led by NHSQIS, were partly subsumed under the ongoing activities of the SPSP in terms of care bundle implementation and compliance and within a broader approach to making use of improvement methodologies within the infection control community.
2. Use of information and data in real time, generated at the frontline of practice, is essential to support the processes of improvement and implementation. The Infection Improvement and Implementation Programme (iiiP) was developed and signed off by NHSQIS board in August 2009 as a quality improvement programme to complement the use of HAI standards data by the HEI.
3. This programme aimed to drive and support a transformational change within infection control teams by creating awareness, capability and capacity in improvement methodologies - such as care bundles - for use by these specialist teams, parallel to the work being carried out with frontline staff by SPSP. A senior project officer was appointed in January 2010 to support the existing medical and nursing consultant posts (comprising the NHSQISHAI team), and iiiP was formally launched at its first national learning session in February 2010. The session was very positively evaluated and support materials were made widely available via an iiiP web page on the NHSQIS website, also launched in February 2010. 6 A programme of iiiP support visits to NHS boards began in March 2010 and a second iiiP learning session - also very positively evaluated - was held in June 2010.
4. In response to a request by the Scottish Government, the NHSQISHAI team moved focus from June 2010 towards supporting boards with the SABHEAT target. Thanks to the iiiP training, boards were already carrying out detailed local analyses to identify priority risk factors and clinical areas for action, and a further round of more detailed diagnostic work was carried out jointly with HPS in August 2010. This confirmed that most boards had particular issues around PVC use, and a new PVC insertion bundle was developed jointly with HPS to complement the existing SPSPPVC maintenance bundle. Many boards also identified issues around blood culture contamination, sometimes involving SABs, and a blood culture checklist was developed, also in collaboration with HPS. These two new tools were issued for testing to selected boards in December 2010, and they incorporate a measurement framework which includes process, outcome and "balancing" measures (the last intended to detect unintended adverse outcomes). The diagnostic process also allowed boards to identify other issues of localised concern in relation to SABs, such as within renal medicine and in relation to skin and soft tissue infections.
5. In January 2011, the work on PVC insertion and blood cultures was fully integrated with the SPSP and a formal 90-day improvement project under that banner is now underway.
Action area 1.5 Support for Care Commission - care of older people and early years - HAI nurse consultant
1. In 2008, the Scottish Government agreed that a three-year consultant nurse, infection control post would be developed and hosted by the Care Commission. Further Scottish Government funding has also been provided to ensure work continues to be progressed during 2011.
2. The role of the consultant nurse has been to lead, influence and facilitate best practice in infection prevention and control at a strategic level, working in partnership within and across sectors. The four overarching objectives for the post were jointly developed and agreed by the Care Commission and the HAI Task Force, as follows.
- To establish a national network of key stakeholders for care homes and early years services, to provide a forum to facilitate and sustain best practice in infection prevention and control. The early years network is well established with a wide range of active stakeholders. Feedback has been very positive and there have been requests for additional network meetings to further develop the HAI agenda in this sector. Plans are in place to further develop the establishment of the care home network through partnership working with the national umbrella body, Scottish Care.
- To work with key stakeholders, such as NES, to ensure educational resources on infection prevention and control for adult care homes and early years are available to the non- NHS/independent sector. A multi-stakeholder education advisory group has been established to agree the resources required. A joint communication was sent to all services outlining the programme and signposting providers to relevant existing education materials. An infection prevention and control induction programme for care homes for older people has been developed on DVD and a complete basic infection prevention and control education programme on DVD, with an accompanying CD workbook, is also nearing completion.
- To facilitate and support the development of HAI surveillance in care homes for older people, building on the findings of the surveillance pilot undertaken in 2009. One hundred providers were recruited to the HPS surveillance programme and, following training, data collection completed in August 2010. Results will be available in 2011. Discussions are taking place with HPS about plans for future data collection.
- To work with key stakeholders to facilitate the inclusion of care homes, early years and independent healthcare services in the National Hand Hygiene Programme. A stakeholder hand hygiene advisory group was formed for consultation and agreement on hand hygiene resources required for each sector. HPS hand hygiene posters were developed and distributed to all relevant services during December 2010. Discussions are ongoing as to how registered care services can continue to promote hand hygiene.
Action area 1.6 Support HPS in the delivery of expertise in decontamination
1. This supported Advanced Course in Sterilisation Technology ( ACIST) training of staff involved in decontamination within HPS.
Action area 1.7 Develop and pilot a methodology to improve learning and develop solutions with regard to endoscope decontamination incidents
1. Work on this delivery area was led by NHSQIS. Following the establishment of a project steering group comprised of relevant stakeholders, a specific dataset for the endoscope "journey" was tested and implemented, ensuring links were made with the SPSP and associated quality improvement methodologies. The final endoscope pilot report was completed and presented to the NHSQIS Board in April 2009, following which NHSQIS recommended the adoption and implementation of the dataset across NHSS.
2. The amended dataset was circulated to NHS boards to update their system to correlate with the national taxonomy in September 2009, with NHS boards being asked to report significant failures to appropriate agencies to facilitate local change and improvement. A small review group has subsequently been set up by NHSQIS.
Action area 1.8 Public involvement programme
1. During the period 2008-2011, Public Involvement and Communications Team ( PICT) members have been involved in all appropriate working groups associated with the HAI Task Force. In addition, PICT has observed public involvement within territorial boards and reported, advised and commented to the HAI Task Force.
2. Activity during this period has been guided by two significant events. In March 2008, NHSQIS published the Healthcare Associated Infection Standards. Standard 2 requires boards to ensure a patient focus and public involvement. Patients, their families/carers and the public should be provided with HAI information relevant to their needs. Additionally, there should be public involvement in the planning and development of measures to prevent and reduce HAI.
3. Most territorial boards now involve members of the public in cleanliness monitoring, infection control, hand hygiene and other HAI-related issues. This Scotland-wide involvement has significantly increased during the period 2008-2011, partly due to the second of the two significant events. This was the establishment of the HEI in 2009. The Inspectorate assesses and reports on compliance with the HAI Standards, including Standard 2, helping to give patient focus/public involvement a higher profile within the HAI agenda.
4. One of the initial objectives at the outset of the Task Force was to "mainstream" HAI public involvement, which was emphasised in the " HAI is everyone's business" message. This has now largely been achieved. It may therefore now be appropriate and in line with good scrutiny processes for public involvement in HAI to be assessed as part of boards' compliance with the Participation Standards published in 2010.
5. In 2009, the role of PICT was considered by the Task Force in line with its own evolving role. It was decided that public representation on the Task Force should be drawn from the Public Partnership Forum's Chairs' Network. Every board is required to have a public partnership forum ( PPF) and must be outward facing and open to all.
6. A letter was sent to all PPF chairs in December 2009 inviting self nomination. The Scottish Health Council oversaw an electoral process resulting in a representative of the Chairs' Network being appointed to the Task Force in 2010. This enables the Task Force to communicate public involvement issues and gain feedback at grassroots level nationwide.
Action area 1.9 Contribute to healthcare associated infection elements of patient experience
1. Learning about the effectiveness of healthcare from the experience of patients is key to improving standards of service delivery. In addition to utilising public partnership forums, the HAI Task Force has remained informed through the "Better Together" Patient Experience Programme, launched in February 2008, on the issues that matter to patients and the public.
2. The programme aims to supports boards and frontline staff in driving forward service improvement, informed by the experience of patients. The programme facilitates the sharing of best practice across NHSS and provides a platform for patients and the public to share their healthcare experiences.
Action area 1.10 Community health partnerships further development
1. A qualitative research study presented to the HAI Task Force by HPS in 2008 had recommended the promotion and encouragement of integration of prevention and control of infection within community health partnerships ( CHPs). As a result, a project was set up to:
- establish baseline information on the infection prevention and control ( IPC) service being provided in NHS and non- NHS public health and community settings;
- clarify the roles and responsibilities of professionals delivering an IPC service in public health and community settings;
- clarify the role of partner agencies (such as care home, nursery and hospice service providers) in providing an IPC service;
- establish key principles of IPC, following analysis of baseline information;
- provide guidance on IPC in community and primary care settings; and
- align with work being undertaken by the Health Protection Advisory Group ( HPAG) capacity and resilience subgroup.
2. IPC guidance for community and primary care settings, based on current scientific evidence and building on existing national model infection control policies and best practice in Scotland, was produced and published on the HPS website in July 2009. 7
3. A wide consultation process was employed to ensure that expert opinion within NHS and non- NHS settings had been taken into account. A final recommendation report 8 was submitted to the HAI Task Force in February 2010, outlining baseline information findings and presenting recommendations to underpin NHS boards' IPC services. Information to support the recommendations was gathered by surveying the IPC services provided by board IPC and health protection teams. Two HPS-facilitated focus groups with IPC staff working in the community and stakeholders from CHPs, the care home sector, nurseries and hospices were held in May 2009. The recommendations contained within the report will continue to be progressed as part of the HAI Task Force deliverables in the coming year.
DELIVERY AREA 2: EDUCATION
Action area 2.1 Establish and address workforce development requirements of infection control teams; Action area 2.2 Development of a programme to support infection control nurse career progression; Action area 2.3 Develop a programme to support the developmental and educational needs of infection control doctors; Action area 2.4 Develop a programme to support the developmental and educational needs of microbiologists
1. Recognising that infection control teams are a multi-disciplinary group of professionals, the engagement to deliver on these four action areas was facilitated by a range of strategies supported by microbiologists, infection control doctors and nurses.
2. NES was tasked to develop an education framework for specialists working in IPC. A training needs assessment was carried out and workshops were held with infection control specialists, from which a questionnaire was developed to validate findings with a wider group. This was further informed by the draft standards for a core curriculum for infection control practitioners in Europe, published by the Improving Patient Safety in Europe project in 2007.
3. The questionnaire survey indicated that Master's-level specialist modules should be developed in: controlling the environment; outbreak management; infection control practices; quality management in HAI; and surveillance and epidemiology. Subjects such as leadership, research and statistics would be covered in core modules. In addition, Scot MARAP recommended that an antibiotic stewardship module should also be made available.
4. The development of bespoke specialist education was commissioned and the contract for developing the modules was awarded to a consortium comprising the University of Dundee (UoD), University of Highlands and Islands Millennium Institute ( UHI) and Glasgow Caledonian University ( GCU). The consortium built on existing programmes to offer a range of Master's-level modules that could be used in continuous professional development ( CPD) or continuing professional education ( CPE) activity or be built into a postgraduate certificate, diploma or full MSc in IPC, appropriate to different professional groups. Recognition of prior learning ( RPEL) was agreed across the consortium.
5. The programme was developed as a modular, online structure as it enabled participants to develop at their own pace professionally, academically and personally. New modules have been developed in:
- concepts of quality improvement and patient safety (commenced September 2009, delivered by UoD);
- measures for improvement in prevention and control of HAI (January 2010, UoD);
- outbreak management (January 2010, UHI);
- controlling the healthcare environment (descriptor was updated and revalidated in November 2009, to commence May 2010); and
- antimicrobial stewardship (a Delphi survey was completed to inform the development of a module descriptor, and outcomes are in development to ensure the specialist nature of this module is achieved).
6. Funding was provided to all NHS boards to facilitate the undertaking of these modules and was well utilised. A full evaluation of the approach taken and learner experience will be undertaken during Spring 2011.
Action area 2.5 Development of an educational programme on caring for patients in isolation
1. Research has shown that patients being treated in isolation can suffer psychologically. NES developed an eLearning education programme to support staff to meet the needs of patients and families experiencing this increasingly frequent situation.
2. The programme aims to help users to understand the psychological, social and physical effects of isolation on patients, regardless of the cause of isolation, and to provide them with techniques and ideas for lessening these impacts through meaningful therapeutic interventions. The anticipated learning time of 1-2 hours is further supplemented by self-directed reading and application to practice. Content is applicable to all grades and staff groups. While hospital-based ward staff and infection control nurses are the main audiences, the programme has also been used by learners from care of older people and rehabilitation areas and by a paramedic.
3. The first learner completed the programme in May 2009, with a further 432 completing to date. Sixty-six per cent of learners feel the programme will "very much impact" on their practice.
Action area 2.6 Development of an educational package on pressure ulcers
1. The Scottish Government commissioned NHSQIS to work with the Care Commission to lead an integrated and coordinated approach to tissue viability across all boards to improve the overall quality of care and reduce the incidence of wounds and wound infections.
2. The programme developed six aims, with NES ensuring the development of a capability framework and commissioning of educational initiatives for providers of tissue viability care.
3. NES consequently developed The Prevention and Management of Pressure Ulcers: An Educational Workbook, 9 a nine-unit programme for anyone in a caring role, be they healthcare professionals or support workers in the NHS or independent care sector, or relatives and carers. The workbook was initially delivered as a single-colour document for download, but after feedback was developed as a reusable colour reference book with a mono printable workplace activities booklet. A copy of both has been circulated to every adult care home in Scotland and has received a very positive response, with 83% of learners feeling the programme would "very much impact" on their practice. The educational package was available to healthcare staff irrespective of their location, including those delivering care in the patient's home.
4. The Creating Viable Options tool 10 sets out key content areas for education to support progressive development in tissue viability expertise for healthcare staff as they progress through their careers. This resource aims to provide organisations and individuals with guidance on preparing education and development programmes on tissue viability for a wide range of healthcare staff and others, such as volunteer workers and carers.
5. Both documents were published in July 2009.
Action area 2.7 Further development of the hand hygiene programme
1. Good hand hygiene is known to be one of the most important interventions in the prevention and reduction of avoidable HAIs. In October 2006, HPS was funded to deliver a National Hand Hygiene Campaign 11 under the auspices of the HAI Task Force. The campaign aimed to raise awareness of the importance of hand hygiene to members of the public and healthcare workers, patients and visitors. It also included national auditing of hand hygiene compliance by healthcare workers in acute healthcare settings, with production of national audit reports. Scotland was the first country in the world to introduce and undertake national hand hygiene auditing.
2. All objectives of this campaign, scheduled to run to March 2008, were met, and it was extended to develop and implement a new programme of work from April 2008 to March 2011. NHS boards were required to reach a target of at least 90% hand hygiene compliance by November 2008, which was achieved.
3. In January 2009, the Cabinet Secretary for Health and Wellbeing stipulated that each NHS board should now work towards a "zero-tolerance approach to non-compliance with hand hygiene", and campaign activities were tailored accordingly. To underline the zero-tolerance approach, compliance monitoring by local hand hygiene health board coordinators ( LHBC) 12 and HPS was stepped up from May 2009, when reporting frequency increased from quarterly to bi-monthly.
4. HPS has published bi-monthly audit reports which are available to view on the HPS website. 13 The latest (January 2011) national compliance figure was 95%. Compliance percentages within NHS boards ranged from 91% to 99%. Overall results for compliance with hand hygiene opportunities between staff groups ranged from 91% to 96%.
5. A national Hand Hygiene Public Awareness campaign was commissioned by the HAI Task Force in 2008/2009, with TV and radio advertising running between January and March 2009. A campaign for health professionals was introduced in 2009/2010 to support the message of zero tolerance in the NHS and a new suite of National Hand Hygiene Campaign materials was distributed to NHS boards in April 2009. 14 The new materials carry more direct messaging than those used previously and were tested beforehand on a range of healthcare professionals in various NHS boards, marking this as an inclusive campaign that sets the right tone and targets the right messages at healthcare workers.
6. The campaign has been characterised by close working with a number of stakeholders, including NHSQIS, NES, HFS and the British Medical Association. This ensured that the message about hand hygiene reached the widest possible audience and made use of the expertise within these organisations.
7. Campaign materials have now been introduced to other settings, such as children's services, care homes, community settings and local authority social work settings. In addition, a resource has been developed to teach the importance of hand hygiene in primary schools, with a report evaluating the effectiveness of the resource recently submitted to the Scottish Government for consideration.
8. The HPS Infection Control Team continues to provide expertise to manage, update and maintain the hand hygiene support activities, primarily through the provision of supporting materials and publicity, including protocols, plans, and materials.
Action area 2.8 Promote inclusion of the Cleanliness Champions Programme in undergraduate nursing and medical courses and extend to healthcare professional and support staff
1. The Cleanliness Champions Programme has been an integral part of the HAI programme of education for some years. Its aims are to improve knowledge among NHS staff of measures they can take to prevent and control the spread of HAIs. It is designed to inform staff across all disciplines of steps that visitors and patients can take for infection prevention and control, promoting a safety culture by advocating for safe practice and ensuring a safe patient environment.
2. The Cleanliness Champions Programme was first embedded into the nursing undergraduate programme in 2004 and has gradually been introduced into medical and dental undergraduate curricula across Scotland.
3. The programme aligns to the standard infection control precautions ( SICPs), comprising 10 self-directed units offering a blended approach to learning through theory, workplace activities and mentorship. Undergraduate programmes have customised the generic version to meet curriculum needs but remain aligned to the learning outcomes for each unit.
4. An evaluation of the impact of the Cleanliness Champions Programme was commissioned in 2008. This aimed to: explore changes in behaviours; gather evidence of changes in clinical practice; and identify barriers to implementing change and factors which facilitate it. Overall outcomes were positive, with recommendations supporting the ongoing delivery of the programme. 15
5. There are currently over 10 000 Cleanliness Champions at NHS board level and approximately 13 000 undergraduates are registered on the programme - they are expected to graduate as Cleanliness Champions over the next four years. Taken together, these figures constitute 16% of the NHSS workforce.
6. Unit 3 of the programme, "Promoting hand hygiene in healthcare", has been developed as a standalone module available for anyone to access. Almost 8000 learners have completed this module. This is in addition to those who have completed the module within the programme.
7. The Cleanliness Champions Programme is being radically reviewed in 2010/2011 to ensure it continues to provide a modern and relevant package of training and deliverables for staff.
Action area 2.9 Develop topic-specific packages relating to HAI and the Scottish Patient Safety Alliance
1. A suite of eLearning short courses (17 in total) to support IPC and patient safety is now available to all healthcare staff, offering education through a range of approaches such as clinical scenarios, tutorials and vignettes. The courses usually take 1-2 hours to complete, supported by further reading and application to practice. Some examples of topic-specific courses developed are shown below.
2.Clostridium difficile infection ( CDI) is recognised as the most common HAI in Scotland. CDI can range in severity from mild to severe and can in some cases be fatal. Effective management hinges on early diagnosis, appropriate treatment of individual cases and infection control measures to minimize the risk of transmission.
3. This CDI scenario-based programme aims to help healthcare workers understand the pathogenesis of Clostridium difficile and how CDI can be prevented, and to provide the best up-to-date knowledge on clinical management of patients with CDI. Content is applicable to a wide range of workers, including medical staff (from consultant to foundation-year level), infection control practitioners, antimicrobial teams, biomedical scientists and clinical expert providers in higher and further education. The CDI clinical scenario was updated in 2011 and an additional clinical scenario depicting severe CDI was added.
4. The programme is available as an eLearning resource with anticipated learning time of 1-2 hours. Although it does not involve formal assessment, questions are set at the end of each section. An underpinning tutorial-based short course on this topic is also available to support the learner to identify CDI and understand the nature of the organism and prevention and control measures.
5. MRSA is a collective term for many different varieties (strains) of the bacterium Staphylococcus aureus that are resistant to the antibiotic meticillin (previously called, and sometimes still called, methicillin). The UK had one of the highest MRSA rates in the world, reporting around 10 000 MRSA bacteraemias per year. Scotland has seen significant reductions in MRSA bacteraemia in recent years, with data from HPS indicating that around 25% of all Staphylococcus aureus is now MRSA. The impact of this situation on the delivery of healthcare remains significant, however, both in terms of human morbidity and mortality and in financial costs.
6. The MRSA scenario-based programme aims to assist healthcare workers to understand the pathogenesis of MRSA and how it can be prevented in hospital and community settings and to support clinical management of patients colonised with, or infected by, MRSA. The programme is available as an eLearning resource with anticipated learning time of 1-2 hours. Content is applicable to a wide range of staff in hospital and community settings, including medical and dental staff, nursing staff, antimicrobial teams and biomedical scientists. An underpinning tutorial-based short course on this topic is also available to support the learner to identify MRSA and understand the nature of the organism and prevention and control measures.
7. Ventilator associated pneumonia ( VAP) is the most common infection acquired by intensive care patients during their illness. Up to 30% of intubated patients may develop VAP, with serious consequences. There is an associated increase in length of stay in intensive care and perhaps an increased risk of death. The aim of the VAP programme is to help healthcare staff prevent VAP. It is available as an eLearning resource with an anticipated learning time of one hour and is applicable to staff working in critical care wards and other areas. Further short courses have been developed to meet the emerging needs of HAI and patient safety and over 5000 short courses have been completed by all grades of staff from a variety of workplace environments. 16
Action area 2.10 Implementation of outbreak management programme
1. An education programme to support infection control teams to effectively manage an HAI outbreak has been developed by NES, working with HPS. The programme addresses the application of national and local polices and evidence for best practice and risk management, and employs the situation, background, assessment, recommendation ( SBAR) tool to deal with a clinical scenario.
2. The main aim is to develop a core, generic education programme to prepare NHS staff and organisations to effectively manage a hospital-based HAI outbreak. Consideration was given to the need to focus on the specific nature of the outbreak rather than a specific organism, reflecting the transferability of outbreak management principles.
3. The Management of Outbreak programme will be an online, scenario-based programme that combines online learning with video detail of "live" discussions. It is intended to reproduce the events surrounding an outbreak of infection in a hospital. The simulated outbreak scenario takes place over five days with events unfolding over time. As the learner answers prompted questions, a calendar will reveal sequential information, taking them onto the next step.
Action area 2.11 Education programme for surveillance coordinators
1. HDL (2001)57, published in 2001, required hospitals to undertake surveillance of HAI and identify a surveillance coordinator. To date, approximately 25 surveillance coordinators have been trained in various aspects of surveillance, including data definitions by members of the Scottish Surveillance of Healthcare Associated Infection Programme team within HPS. HPS facilitates an annual surgical site infection ( SSI) coordinators meeting, and a need for epidemiology training was identified by the coordinators via this forum.
2. HPS has developed local reporting mechanisms, launching an online system in 2007/2008 which enables SSI coordinators to identify local SSI rates in "real time". There was a need for training and development for staff in this area to maximise the potential use of surveillance data. HPS consequently set out to deliver a three-day training course in HAI epidemiology and statistics for surveillance staff. The course is accredited by the Center for Disease Control ( CDC).
3. HPS also developed a project to: identify a competency profile for surveillance staff; evaluate knowledge levels for surveillance staff in HAI surveillance and epidemiology pre and post course; identify further HAI training and education requirements for surveillance staff; and develop with NES an HAI education programme for current and future surveillance staff.
4. In September 2008, the three-day CDC-accredited course on HAI epidemiology and statistics was offered to all staff working in surveillance roles throughout the NHS and independent sector in Scotland. Course evaluation highlighted the need to further explore the training needs of this cohort of staff, particularly in relation to the basics of surveillance, statistics, presentation of information and negotiating or dealing with difficult situations.
5. From this, NES and HPS prepared a three-day education package to meet the needs of all staff working in surveillance roles. The programme included surveillance methodologies, definitions and reporting tools, change management, influencing/negotiation skills and effective communication training. The technical training days were developed as webcasts that participants were able to access locally - this was particularly helpful for those in remote and rural locations.
6. A degree-level surveillance module was developed in 2010 and offered to staff employed in surveillance roles across NHSS. The module was delivered online via UHI and was funded by the Scottish Government through NES. A total of 14 surveillance staff across NHSS have completed the module to date.
7. Also in 2010, HPS collaborated with NES to develop an SSI surveillance training webcast to provide consistent remote access training for SSI surveillance. The aim is to ensure SSI surveillance training is provided consistently for all new surveillance or clinical staff collecting data. As post-discharge surveillance until day 10 is now a mandatory requirement for Caesarean section procedures, a separate SSI surveillance webcast was also developed for community midwives.
Action area 2.12 Development of a neonatal vascular access programme
1. While the general principles regarding insertion and management of a CVC are the same for adults and neonates, extreme preterm babies are dramatically immunocompromised and are prone to recurrent infection. Practitioners are required to insert central and peripheral lines within the confined access of incubators, and neonates also have extremely compromised skin.
2. NES funded expert practitioners in NHS Lothian to explore evidence from the literature to guide the content of this programme. It aligns with the NESCVC access programme for adults and the Central Vascular Maintenance care bundle.
3. The programme aims to heighten staff awareness of the particular care needs of neonates receiving intravenous therapy, improve the knowledge and skills of the multidisciplinary team caring for neonates, and promote best practice in the prevention and management of infection associated with central vascular lines in neonates. It is available as an eLearning resource with anticipated learning time of 10-15 hours, supplemented by self-directed reading, and is aimed at medical and nursing staff working within a neonatal intensive care unit and infection control practitioners. However, any staff member with an interest in preventing infection and the care of CVCs will find it valuable.
Action area 2.13 Develop an educational package on prevention of infectious diseases in older people
1. Current concerns about antibiotic resistance, infectious disease and the growing number of older adults all point to an increasing need for healthcare staff to develop expertise in the care of this population. Meeting these HAI education needs required a recognition, first, of the person-specific HAI indicators of older people, and second, of the environment-specific issues for older people living in care homes.
Presentation of infections in older people
2. Certain infections are more prevalent in older people than in younger adults and are associated with atypical clinical manifestation. Infections in older people tend to have few symptoms and delay in diagnosis of infection increases the risk for mortality and morbidity. It is estimated that two thirds of patients in acute hospital care at any one time are aged over 65 years.
3. An eLearning educational programme has been developed to recognise the physiological changes in ageing and how they can affect both the presence and response to infection in older people. The programme highlights the ageing process signs and symptoms, describes the identification of infection in older people and diagnosis, treatment and preventative measures.
Infection prevention and control of infections in care homes for older people
4. Working in partnership with the Care Commission, NES has developed a comprehensive programme of education offering a core induction module and a full education programme using a blended learning approach delivered on DVD and CD.
5. The core induction module offers an opportunity to develop a national approach to induction across all care homes for older people. This resource is supported by teachers' notes to be used in individual or classroom settings.
6. The full programme aims to provide education in basic infection prevention and control aligned to the SICPs, information on outbreaks, and infection prevention and control relating to specific microorganisms and infections, all relative to a care home environment.
7. It is anticipated that the programmes will have some transferability across all care homes and care at home settings.
DELIVERY AREA 3: SURVEILLANCE, INFORMATION AND AUDIT
Action area 3.1 Continued development of surgical site infection surveillance
1. SSI surveillance has been mandatory in Scotland since 2001. Mandatory requirements in the current programme are hip arthroplasty inpatient and readmission surveillance to 30 days and Caesarean section inpatient and post-discharge surveillance to day 10. Additional voluntary surveillance may be carried out.
2. The objective of this action area is to further expand the existing SSI surveillance system and to align it with European Centre for Disease Control ( ECDC) surveillance requirements and other national surveillance centres within the UK.
3. The National HAI Steering Group and Programme Board recommendation that Caesarean section procedures should have mandatory post-discharge surveillance carried out to 10 days, and not 30 days as previously, has been implemented.
4. System updates were made to enable antibiotic prophylaxis to be monitored from April 2009. This enables quarterly compliance with Scottish Intercollegiate Guidelines Network ( SIGN) Guideline 104 ("Antibiotic Prophylaxis in Surgery") 17 to be sent to SAPG and NHS boards. The fifth version of the SSI surveillance protocol has been produced and the Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision) ( OPCS4) codes have been aligned with HPA changes to the web reporting system.
5. Compliance with reporting the National Nosocomial Infections Surveillance System ( NNIS) risk index has improved (11% of records were incomplete in 2009, compared to 27% in 2008). A Surgical Site Infection Reporting System ( SSIRS) user questionnaire identified further improvement requirements and these have been implemented and integrated into a training day run in conjunction with NES.
6. A number of NHS boards have participated in the pilot of the ECDC "light" protocol for SSI surveillance in 2011. The protocol requires collection of denominator data, with detailed surveillance data only being collected for patients with an SSI. The aim is to enable data to be collected with reduced resources. The pilot has been conducted within four NHS boards for abdominal hysterectomy, major vascular surgery and breast surgery procedure categories. A report on the feasibility of this pilot study will be available in 2011.
7. To obtain information on causative microorganisms for SSIs, a data linkage pilot was conducted in 2010. This exercise links data from SSIRS and the Electronic Communication of Surveillance in Scotland ( ECOSS). ECOSS data are entered by laboratory staff within the boards. A report on the feasibility of this data linkage pilot will be available in 2011.
Action area 3.2 Further development of catheter-associated urinary tract infection surveillance, in particular targeting medicine, surgical (and orthopaedics), care of the elderly and in long-term care
1. Urinary tract infections ( UTIs) are the most common infections acquired in hospitals and long-term care facilities. This action area was taken forward by HPS and the aims were to:
- redevelop the current catheter associated urinary tract infection ( CAUTI) surveillance programme for use particularly within care of older people, long-term care, medicine and surgical (orthopaedic) specialties;
- actively promote and encourage CAUTI surveillance within all medical and surgical specialties, particularly orthopaedic; and
- review data collection methods for CAUTI surveillance within all specialties.
2. Two CAUTI protocols were developed, one for use within care of older people and long-term care settings and one within acute settings. These were used in pilot studies in a number of sites recruited by HPS.
3. A training package for data collection and surveillance methodology was developed to ensure that national data were both reliable and comparable. This was delivered to all nominated data collectors within participating hospitals. HPS facilitated the implementation of surveillance in each volunteer hospital.
4. Results from the pilot study indicated that the redeveloped methodology and definitions were relatively robust for use with the study population. Valuable data on catheter use and CAUTI incidence rates within care of older people settings were collected. These data can be used to focus on care practice areas with respect to preventing CAUTI and improving patient safety. The surveillance protocol and collection tool could be adapted for use within care homes and other long-term care facilities.
Action area 3.3 Further exploration as to reasons for variation in Staphylococcus aureus bacteraemia rates
1. Mandatory quarterly reporting of MRSA bacteraemia was introduced in 2002 (meticillin-sensitive Staphylococcus aureus ( MSSA) bacteraemia reporting was made mandatory in 2006).
2. The objectives of this HPS-driven action area were to:
- conduct a longitudinal analysis of the relationship between SAB and hospital characteristics that may explain variation;
- model the impact of changing hospital determinants on rates of SAB, patient outcomes and hospital costs to understand the potential value of changing determinants of SAB.
3. HPS worked with modellers at Dundee Medical School to examine linking the HPS dataset with other nationally available data to examine factors describing SAB. The report was completed by June 2010.
4. The mandatory SAB dataset now has over five years of validated data. The epidemiology of SAB, however, is still not well understood and exploration of reasons behind variation in SAB rates between NHS boards is now required. This will be taken forward as part of future HAI Task Force deliverables.
Action area 3.4 Implementation of intensive care unit surveillance of ventilator associated pneumonia and central venous catheter infections
1. The first Scottish national HAI prevalence survey 18 reported that 9.5% of patients were affected by an HAI during their hospital stay. The same study found that 27.1% of patients in intensive care units ( ICUs) were affected by HAI.
2. The HAI in the ICU Surveillance Programme was established in 2008, with data collection commencing in January 2009. It contributes to the list of voluntary surveillance programmes offered by HPS and has been developed in conjunction with the Scottish Intensive Care Society Audit Group ( SICSAG).
3. The protocol for ICU surveillance was developed and training was delivered for all staff collecting HAI data. SICSAG has developed tools to enable each ICU to feed back data on their HAI rates to the SPSP. Eighty-seven per cent of the general ICUs within Scotland contributed to the first national report, published in August 2010.
4. Throughout 2009 and 2010, 19 ICUs participated in a voluntary programme of surveillance. The 2010 ICU pilot surveillance report will be published in 2011. Validation of data received from all contributing ICUs has been carried out by HPS to ensure data quality. This information has been reported to SICSAG.
Action area 3.5 Repeated targeted prevalence surveillance
1. The objectives for this HPS-led project were to:
- evaluate the Scottish national HAI prevalence survey methodology as a tool for monitoring HAI and the effectiveness of interventions;
- develop a consistent methodology and training package for prevalence surveys that will allow the impact of measures taken nationally to reduce the burden of HAI to be evaluated through an analysis of trends over time;
- train local hospital staff in Scotland to undertake point prevalence surveys using the refined methodology and definitions used in the national survey; and
- develop a publication plan and deliver publications to utilise the national survey dataset, particularly the overall results and data on antibiotic usage, statistical analysis, prevalence of invasive devices and further analysis of specialties.
2. There are important limitations in comparing the results of repeated point prevalence surveys that should be acknowledged. The prevalence figure is a snapshot of the burden of infection at a specific point in time and is subject to variation. The patient case mix may also vary over time. While prevalence surveys offer a fast method of assessing changes in the burden of infection over time, it is recommended they be used alongside existing incidence surveillance monitoring programmes.
3. A fully integrated HAI point prevalence data collection tool was developed using the Scottish national HAI prevalence survey methodology. The data collection and reporting tool is held on a tablet personal computer and is offered to boards wishing to participate in HAI prevalence surveys. The tool includes a database that has built-in validation to ensure that data are checked as they are entered.
4. A comprehensive training package, delivered over two days, was developed. Sessions have been attended by a wide range of NHS staff, including surveillance nurses, surveillance coordinators, microbiologists, infection control nurses, infection control managers and infection control doctors.
5. Data from the national survey have been used to inform national policy and have provoked international interest. The data were presented at national and international conferences and have been published in a peer-reviewed journal. 19
Action area 3.6 Development and implementation of the second national point prevalence survey
1. The first Scottish national HAI prevalence survey was carried out by HPS between October 2005 and September 2006. All acute hospitals beds and a 25% sample of non-acute hospitals were surveyed. Data were collected over one calendar year by independent data collectors employed by HPS. The survey reported that 9.5% and 7.3% of patients in acute and non-acute hospitals, respectively, had a HAI at the time of survey.
2. This deliverable requires the development and implementation of a second national HAI prevalence survey. The protocol, training package and data collection tool developed for the first national survey and the second-phase local surveys are ready for use in the second national survey. Planning and implementation of the second survey will be less resource intensive relative to the first: the comprehensive lessons learned and the documents and project plans produced during the first survey will provide guidance in the planning and implementation of the second.
3. It is intended that a second prevalence survey will be undertaken in 2011 using a newly developed ECDC protocol that will allow data comparison with the findings from the first prevalence survey. This approach will also enable Scotland's burden of infection to be compared across the UK and Europe. The intention thereafter is to undertake annual prevalence surveys and use the outcomes from these as the Healthcare Quality Strategy for NHSS outcome measure for determining progress in reducing the burden of HAI in Scotland.
Action area 3.7 Vascular catheter surveillance
1. CVCs, which are indicated for the repeated administration of chemotherapy, antibiotics, parental feeding and blood products and for venous access during renal replacement therapy, are the leading cause of device-related bacteraemia. Although CVCs provide life-saving vascular access, their invasive nature puts already-vulnerable patients at risk of life-threatening local and systemic infections. The Scottish national HAI prevalence survey reported that 3.2% of patients in acute care hospitals had a CVC in situ at the time of the survey, indicating a considerable "at-risk" population in acute care.
2. In recognition of the above and as a result of there being no current method for surveillance of patients with long-term CVCs, it was proposed that a methodology for incidence surveillance be developed. The feasibility of implementing the surveillance system for use at local and national levels will be tested during a pilot study and recommendations for the future development of the surveillance system will be made.
3. In addition to development of a prospective incidence surveillance system, a feasibility study to establish whether data linkage between HPSStaphylococcus aureus data and the Scottish Renal Registry dataset could be used to monitor CVC-related infection on an ongoing basis was developed. It is anticipated that this voluntary programme of surveillance will produce a fit-for-purpose data collection tool that will enable collection of central vascular catheter - renal insertion ( CVC- RI) data that enable measurement of the incidence of CVC- RI locally and nationally.
Action area 3.8 Surveillance of antimicrobial resistance; Action area 3.9 Surveillance of antimicrobial resistance drugs
1. HPS produced, for the first time, an annual epidemiological stock take of HAI in Scotland. The aim of the report, published in April 2010, was to identify key information on HAI in Scotland, demonstrate the burden of infection and trends in infection incidence, share supplementary epidemiological and microbiological data from the national reference laboratories, and identify future priorities.
2. HPS also produced a report on AMR for the first time in January 2010. It reported the use of systemic antimicrobials and patterns of antimicrobial resistance in key organisms. A supplementary AMR briefing report was also prepared for the Task Force so that future planning for prevention and control of infection will be based on the most up-to-date intelligence available in Scotland. The January 2010 report represented baseline data from which future reports can assess the effect of national initiatives to minimise AMR.
3. The second report, published in January 2011, shows that primary care patients in Scotland were prescribed 44 500 fewer antibacterials in 2009 as recommendations on prescribing took hold. This 1.6% fall in the number of prescribed items per 1000 population per day (items/1000/day) is the first annual reduction since 2004.
4. More information about the work undertaken by HPS to support implementation of the Scot MARAP is detailed under action area 4.9.
Action area 3.10 Further development of bacteraemia surveillance ( ECOSS interface)
1. HPS receives electronically via ECOSS all positive reports of significant organisms from all NHS laboratories in Scotland. This is an established national system that is significant for surveillance purposes.
2. ECOSS is now the main repository for data that are fed out to groups within HPS for reporting and analytical purposes. ECOSS provides a core service to ensure that the system is able to provide information that is required for surveillance, detection of outbreaks and alert organisms.
3. Since January 2010, ECOSS has been the mechanism for laboratories' statutory duty of notifying NHS boards about infectious diseases.
4. The system of automated data collection from testing laboratories has proved more secure than previous paper-based systems. Additionally, the ECOSS website has been made accessible to health professionals who monitor the incidence of infection. The system continues to be developed, based on valuable feedback from all ECOSS users.
Action area 3.11 Develop a prevalence methodology for pressure ulcers (linked to the national approach to tissue viability)
1. This has been subsumed as part of action area 3.6 and will be incorporated into the planned NHSS-wide annual prevalence surveys.
Action area 3.12 Knowledge management of HAI outbreaks
1. Knowledge management combines good practice in purposeful identification, management and sharing of information with a culture of organisational learning to improve processes for safety and effective utilisation of resources. Knowledge management of HAI outbreaks enables the extensive tacit and explicit knowledge generated during outbreaks to inform means of reducing the risk of further HAI outbreaks and to manage outbreaks more effectively.
2. HPS has endeavoured to identify and map the current knowledge management of HAI outbreaks and establish what optimal knowledge management would look like as a means to implementing first steps towards effective knowledge management of HAI outbreaks in NHSS.
3. The final project report, submitted to the HAI Task Force in April 2009, was able to draw on experience gained from involvement in outbreak management in dealing with norovirus, although the scenarios that have been developed are applicable to all HAI outbreaks.
4. Work is currently underway to produce a status report on outbreak surveillance and to develop a HPS outbreak reporting system. This will describe how outbreaks and incidents are currently dealt with at HPS, highlighting key components of outbreak identification, assessment, management, documentation and dissemination.
Options for a HPS-wide outbreak surveillance system that will facilitate more rapid reporting and better management, rather than being focused solely on the collection of epidemiological data when the outbreak is over, are being reviewed.
5. This work on knowledge management has been utilised in an evaluation of norovirus outbreaks and in designing preparedness tools to assist ICTs in their efforts to reduce the impact and risk of outbreaks in healthcare premises.
Action area 3.13 Explore care home surveillance
1. Older people are more susceptible to infection due to increased age and underlying health problems. There is an additional infection risk when numbers of older people live together, as in care home settings. Residents are also encouraged to maintain their independence and continue to be part of the local community, and consequently will be exposed to infections such as colds, influenza and norovirus.
2. In 2008, the prevalence of infection in Scottish care homes was unknown. HPS therefore carried out a project that aimed to estimate prevalence within a small sample of care homes and to develop and test a methodology for point prevalence surveys that would allow care home staff to monitor infection in homes that employed trained nurses. A protocol was developed to allow care home staff to monitor HAI by undertaking prevalence surveillance using the same methodology as the Improving Patient Safety in Europe ( IPSE) surveillance of nursing homes HAI protocol.
3. The results indicate that the developed methodology offers a feasible and robust means of collecting data on infection in care homes that employ registered nursing staff. The methodology can be used in future to identify key infection types for targeted interventions at local and national level. In 2010, HPS recruited 83 care homes in Scotland to voluntarily participate in the ECDC Healthcare Associated Infection in Long Term Care Facilities ( HALT) prevalence survey. Results of this survey will be in available in 2011.
DELIVERY AREA 4: GUIDANCE AND STANDARDS
Action area 4.1 Development of supporting materials for implementation of the model policies for transmission-based precautions
1. National model infection control policies provided by the ICT at HPS aim to achieve greater consistency in practice and to maintain and improve infection prevention and control standards across all care settings in Scotland.
2. SICPs model policies and associated literature reviews were first published on the website in February 2006 and were last updated in February 2009 (see action area 4.2 below). Model policies on transmission-based precautions ( TBPs) and associated literature reviews were published on the HPSICT web pages in April 2008. This area of work now focuses on the development and delivery of a collection of practical job-related materials and tools to aid implementation and maintenance of the policies in practice. These measures underpin all infection prevention and control activities in NHSS and beyond and support the current HAI reduction agenda.
Action area 4.2 Developing further new model policies
1. SICPs are the basic safety measures necessary to reduce the risk of transmission of micro-organisms from both recognised and unrecognised sources of infection. They are intended for use by all healthcare staff in all healthcare settings at all times, whether infection is known to be present or not, to ensure the safety of patients, healthcare staff and visitors to the healthcare environment.
2. TBPs are additional precautions used in conjunction with SICPs when a patient is known or suspected to be infected with an infection transmitted by droplet, contact and/or airborne spread.
3. The publication of the HPSSICP model policies in 2006 and the subsequent TBPs in 2008 aimed to develop evidence-based infection control guidance that would standardise SICP and TBP procedures across NHSS. However, while the literature reviews were considered valuable, NHS boards have continued to retain their own local infection control manuals, which include SICPs and TBPs; as a result, there has been variation in practice across NHSS.
4. An evaluation of the HPS model policies conducted in 2009 (see action area 4.13 below) highlighted that healthcare staff found them difficult to translate into practical application and that there was a desire to have a more explicit link between practice, healthcare setting and quality of evidence.
5. The aim now is to ensure that the infection control model policies provide all healthcare staff working within hospital settings in NHSS with brief (checklists) but comprehensive guidelines covering the 10 SICPs and 3 TBPs. The literature reviews will outline and rank the current evidence for SICPs and TBPs, informing recommendations for practice and research. The rework of the extant infection control model policies on SICPs and TBPs will include the revision of literature-reviewing methodology and the development of supporting materials as appropriate.
6. The literature review process will:
- review and amend the original literature review strategy process, making the process more systematic;
- develop strategies to inform auto alerts, consequently ensuring the continued identification of current relevant information and research material;
- align internal HPS standard operating procedures with revised strategies and develop documentation for external transparency;
- formalise the methodology, organisation, recording and electronic storage of the literature searches and reviews; and
- identify evidence/research gaps in the literature relating to the model policies, in particular the SICPs, and create research studies to begin to develop an enhanced evidence base in conjunction with service providers.
7. The aims for the model policies are to rework the content and format of extant policies in collaboration with national partner organisations and end users, ensuring a clear, easy-to-use design that is acceptable, and to develop an effective dissemination and implementation strategy.
8. Work on developing the model policies will continue into 2011/2012.
Action area 4.3 Pilot study of the recommendations in the MRSA health technology assessment
1. The HTA report on the clinical and cost effectiveness of screening for MRSA was published in October 2007. The report included results from a systematic review of the literature, focus groups with staff and the public, a survey of hospital screening practices and economic modelling. It identified screening of all patients for MRSA colonisation by a laboratory test as the most effective strategy in reducing prevalence and preventing infection.
2. A primary study was set up in acute inpatient care settings to assess whether screening all patients for MRSA was effective in preventing MRSA infection, as predicted. This involved a summative evaluation of at least one year of data collection.
3. Pilot screening in Scotland began in 2008/2009 in three pathfinder boards ( NHS Ayrshire & Arran, NHS Grampian and NHS Western Isles) and an interim report was published by HPS in March 2009.
4. Following publication of the interim pathfinder report, the Scottish Government announced that from end January 2010, all boards would be required to screen the majority of elective patients to acute hospitals and all emergency admissions to the four specialties identified in the interim report as having the highest prevalence of MRSA colonisation at that time (nephrology, care of older people, dermatology and vascular surgery).
5. The four volumes of the final pathfinder report, published by HPS in February 2011, 20 detailed the information gathered during the pathfinder study and from 10 special studies. A number of recommendations on what would be required to effectively implement MRSA screening in NHSS and what the effects of implementing universal screening may be, based on the observed data and the re-worked NHSQIS model data, were made.
6. The majority of public health principles against which MRSA screening has been assessed are now met. The benefit of this work is that the Scottish Government was able to assess the costs and the consequences of implementing MRSA screening. This work has also enabled the HPS team to develop a national approach to MRSA screening, share the lessons learned during the pathfinder study with other NHS boards, improve the quality of patient information and develop a standardised laboratory protocol in NHSS.
Action area 4.4 Full implementation of MRSA screening programme; Action area 4.5 Implementation of MRSA control strategy
1. All NHS boards have introduced targeted screening for MRSA since January 2010 and are being supported to embed this practice, while ensuring it is being delivered as efficiently and effectively as possible.
2. To further inform any future policy approach to MRSA screening, HPS was asked by the Scottish Government to undertake further special research studies (the first investigating the use of clinical risk assessment and multiple body site screening and the second investigating acquisition of MRSA within three of the pathfinder hospitals). The final reports on these studies were published by HPS in February 2011. 21
3. HPS is also developing key performance indicators for the national rollout programme to monitor implementation and prevalence of colonisation within the specified screening areas.
Action area 4.6 Implementation of the NHSQISHAI Standards and self-assessment tool
1. Revised national HAI Standards were issued by NHSQIS to NHSS in March 2008, followed by work to develop a set of self-assessment questions for boards. The signed-off HAI Standards self-assessment tool was sent to all NHS boards in March 2009 for them to complete.
Action area 4.7 Formal review against the NHSQISHAI Standards
1. The HEI was set up in July 2009 to inspect NHS boards against the NHSQISHAI Standards using the self-assessment tool as a framework. Inspections began in September 2009. Reports from both announced and unannounced inspections and the associated improvement action plans are published and, in November 2010, the Chief Inspector published her annual report in which the key themes from the first year of inspections were detailed.
Action area 4.8 Develop national guidelines on taking samples for diarrhoeal patients (including Clostridium difficile)
1. The need for these guidelines 22 was identified through validation studies used to assess the efficacy of the national Clostridium difficile associated disease ( CDAD) mandatory surveillance programme, which identified a tendency in some hospitals to oversample patients whether or not they had displayed symptoms of diarrhoea.
2. The guidelines were developed following literature searching and reviewing by members of the HPS project team and wide consultation on drafts. They aim to:
- ensure consistency of the approach to obtaining samples for diarrhoeal patients (including patients infected with Clostridium difficile and a spectrum of the most common clinically significant bacterial, viral and parasitic pathogens);
- promote the standardisation and quality of diarrhoeal samples taken across NHSS; and
- support IPC programmes through early diagnosis of infectious agents that may occur as a result of contact exposure in healthcare premises.
Action area 4.9 Implementing Scottish Management of Antimicrobial Resistance Action Plan recommendations
1. Prudent prescribing of antibiotics is key in the prevention and control of Clostridium difficile infection. In March 2008, the HAI Task Force replaced the Antimicrobial Resistance Strategy and Scottish Action Plan with a new five-year strategic plan: the Scottish Management of Antimicrobial Resistance Action Plan (Scot MARAP).
2. The Scottish Antimicrobial Prescribing Group ( SAPG) oversees Scot MARAP and over 2008 and 2010 took forward the recommendations of Scot MARAP through five work streams: organisation, information, education, infection management and community-acquired pneumonia.
3. SAPG is now fully engaged with national stakeholders and antimicrobial management teams throughout Scotland in developing a national consensus approach to the use of antimicrobials. The completion of data collection systems for prescribing and antimicrobial resistance surveillance now provides essential information to support and inform SAPG and local AMT antimicrobial stewardship agendas. Development of data collection systems for quality improvement and collaboration with the SPSP have allowed SAPG to measure the impact of its interventions.
4. Key achievements will be detailed in the forthcoming SAPG progress report 2008-2011, which will be published on the SAPG website, 23 and include:
- increased clinical leadership and engagement with antimicrobial stewardship within NHS boards;
- the development of national guidance on antimicrobial policies for hospitals and primary care to restrict the use of antibiotics associated with CDI;
- the development of prescribing indicators for hospital and primary care to support the CDIHEAT target, including the development and use of the Institute for Healthcare Improvement Extranet to share and disseminate compliance data;
- the development of systems to assess implementation of SAPG guidance and evaluate the impact on clinical outcomes and occurrence of unintended consequences caused by changes in antimicrobial policies; early evaluation of prospective data and experience from all boards has demonstrated reduction and improved quality of antibiotic use, which has made a significant contribution to the decreased rates of CDI nationally;
- the integration of quality measures for antimicrobial prescribing into the HEI process;
- the publication of joint annual reports on AMR and use;
- the development of a core set of national prescribing indicators for antimicrobials used in primary care settings;
- the development of a national framework for surveillance of antimicrobial use and resistance;
- the development of the Hospital Medicines Utilisation database ( HMUD) to provide information about antimicrobial use in hospitals;
- national participation in the European Surveillance of Antimicrobial Consumption ( ESAC) 2009 point prevalence survey of antimicrobial use in European hospitals;
- the development of an alert system to identify emerging rare resistant pathogens that can cause serious clinical problems in "real-time" to ensure appropriate antimicrobial therapy;
- the development of a comprehensive education framework and resources on antimicrobial stewardship for undergraduate and postgraduate healthcare professionals, including resources for CPD;
- the development of a care bundle to optimise the management of community-acquired pneumonia as a model for future quality improvement work;
- the provision of public health information to reduce patient expectation for antibiotics in self-limiting viral infections, and national participation in European Antibiotic Awareness Day; and
- completion of a health impact assessment of antimicrobial resistance and the implications this has for the population of Scotland, which helps inform future healthcare policy.
Action area 4.10 Standard operating procedures for testing of key organisms
1. A major achievement in 2009/2010 was the standardisation and automation of antimicrobial susceptibility testing of blood cultures, which was achieved, through the Scottish Microbiology Forum, by the implementation of VITEK 2 systems (an automated identification and antimicrobial susceptibility testing system) in laboratories across Scotland.
2. The VITEK 2 system provides high-quality and comprehensive comparable AMR information for all NHS boards in Scotland that will allow detailed analysis of resistance trends and emerging new resistances at national level. Laboratories are currently expanding their use of VITEK 2 to testing urine, sputum and other types of specimens.
3. The development of a solid IT infrastructure for reporting surveillance data from the laboratories to HPS was a key priority in 2010. This has enabled fully automated reporting of high-quality resistance data to HPS in all boards.
4. Another key activity within the information work stream is the Scottish surveillance programme for monitoring antimicrobial resistance in clinically important pathogens, which is aimed at preserving the effectiveness of the currently available antimicrobial medicines by supporting NHS boards in their long-term strategic planning of antimicrobial prescribing and infection control policy development and to identify new emerging patterns of resistance. The surveillance programme is modelled on the EARSS24 (European Antimicrobial Surveillance System) and, in this initial phase, is focused on monitoring antimicrobial resistance in invasive isolates from hospital patients with bloodstream infections (caused by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae and Enterococcus faecium and faecalis).
5. The national surveillance programme went into its second year in 2010, when data collection procedures were further consolidated and expanded by the inclusion of reports on invasive Acinetobacter baumannii.
6. Guidance was also produced in collaboration with the Scottish Salmonella Shigella and C. difficile Reference Laboratory and the Scottish Microbiology Forum on standardised testing and confirmation of Clostridium difficile.
7. Preliminary work was undertaken to expand the national surveillance of AMR by collecting baseline data on which surveillance of key pathogens from UTIs can be developed and for monitoring of key resistance mechanisms such as extended-spectrum beta-lactamases ( ESBLs) and carbapenemases. Both these projects will be taken forward in 2011.
Action area 4.11 Outbreak management guidance
1. Outbreaks in healthcare facilities in NHSS occur and can cause significant morbidity and mortality. HPS undertook to produce tools to assist in optimal investigation and management of outbreaks. Theories used in the process of producing the tools were human error theory, high-reliability theory and the developing theories around patient safety. In addition, "human factors" were considered during the construction of all tools in the pursuit of ensuring that rules and guidance make it easy for healthcare workers to do the right thing.
2. HPS set up the Hospital Outbreak Advisory Group ( HOAG) to oversee the production of the following tools:
- an outbreak management investigation and control tool;
- the hospital outbreak management process; 25
- a tool for the effective management of norovirus; 26
- a knowledge-based support tool for outbreaks where rules have not been devised; 27
- the Hospital Infection Incident Assessment Tool ( HIIAT); 28 and
- a CDI trigger tool listing the actions that must be taken as soon as a CDI trigger is reached and for every day thereafter until the incident is closed. 29
3. HOAG has also overseen the updating to the Watt Risk Matrix ( HIIAT) and is continuing to develop the control measure listing tool and the outbreak investigation assessment tool.
4. The outbreak management tools have been designed to reduce the risk of outbreaks and better manage their control. Those developed so far will assist ICTs by reducing uncertainty and enabling better reasoning and decision-making. Teams are gaining experience in the use of these tools, which are subject to ongoing review, and a recent survey of opinions on the HIIAT has been undertaken with suggestions for change made to the reporting process.
HAI Compendium of Guidance
5. In recognition of the fact there was no single point-source for all national guidance on the prevention and control of HAI, HPS was invited by the Scottish Government to lead on the development of an HAI Compendium of Guidance to bring together all the HAI guidance documents available to NHSS staff from various stakeholders and specialist advisory bodies. The compendium:
- includes all current national HAI guidance produced since 2001 by stakeholders for NHSS (Scottish Government, HPS, Health Protection Network ( HPN), HFS and NHSQIS) and any HAI guidance developed for NHSS by specialist advisory bodies;
- includes national ( UK) HAI guidance advocated for use in NHSS; and
- provides NHSS staff with an overview of all up-to-date HAI guidance, as well as the key messages from the guidance and all associated supporting materials such as checklists, care bundles, patient information leaflets and training scenarios.
6. It also contains all current national guidance documents on HAI produced since 2000 and is available on the HPS website. 30 The initial format is a downloadable PDF document from which all the included guidance documents and supporting materials are accessible. It is indexed by publishing organisation and by subject groups (the built environment, SICPs, surveillance, for example) to aid retrieval of documents. It is a "living" document and will be reviewed on a quarterly basis (March, June, September and December) with any additions from the various stakeholders and specialist advisory bodies being highlighted and added.
7. It is important that the Compendium is presented to NHSS staff in a user-friendly format, and the aim during 2011/2012 is to develop the PDF resource into a fully searchable online database.
Action area 4.12 Rolling programme for reviewing existing national programmes
1. The principal of review is one that has been integral to the delivery agenda throughout the last three years. Specific examples include: the review of HEAT targets; changes to the standards of compliance with hand hygiene; a review of the National Cleaning Services Specification and the developing policy approach to MRSA screening.
Action area 4.13 Evaluation of model policies
1. The HPS infection control model policies aim to achieve greater consistency in practice and the maintenance and improvement of standards related to the prevention and control of HAI.
2. The objective of the evaluation process was to determine if key stakeholders within NHS and non- NHS health and social care settings were using the model policies in accordance with their original aims and objectives and identifying if they remained fit for purpose.
3. NHS and local authority personnel were surveyed by questionnaire about their awareness and use of the model policies. The findings of the survey were presented in a final report to the HAI Task Force, who approved the recommendations. These called for:
- the provision of a streamlined and real-time system of literature searching focusing not only on the literature, but also on evidence for possible flaws in existing policies, changes in legislation and position statements from learned societies;
- a reworking of the content and format of model policies in collaboration with national partner organisations and end users, ensuring a simple, easy-to-use design that makes it easy for healthcare workers to do the right thing; and
- the development of an effective dissemination strategy to address the issues highlighted by the survey.
4. As a result of these recommendations being accepted, development of supporting materials to facilitate the implementation of the model policies for TBPs has been deferred until completion of the rework of model policies (see action area 4.2).
DELIVERY AREA 5: PHYSICAL ENVIRONMENT
Action area 5.1 Further development of the monitoring framework for the NHSS National Cleaning Services Specification
1. Work in this area has been progressed by HFS. The aims have been to provide a consistent approach to cleaning and cleaning methodology across NHSS and to put in place a system of audit of standards of cleanliness, principles and processes within the National Cleaning Services Specification ( NCSS), which sets a minimum standard of cleaning methodology and quality across NHSS.
2. The original cleaning specification was developed and distributed to NHS boards in May 2004. The current version was developed and distributed in 2006 and revised again in 2009. Development and revision of the NCSS has been taken forward by the HFS Domestic Advisory Group.
3. HFS provides a quarterly cleaning standards report to the Scottish Government which provides data on compliance with the requirements set out in the NCSS. It includes data on the 16 Scottish health boards that offer inpatient services: 14 operational boards (results are shown for each board and for acute teaching hospitals and acute non-teaching hospitals); and two special health boards (the Golden Jubilee National Hospital and the State Hospitals Board for Scotland).
4. The reports indicate the status of each board using a traffic light system.
Compliance above 90%
Compliance between 70% and 90%
Compliance below 70%
5. The reports also highlight any issues regarding noncompliance with the cleaning specification. NHS boards or major sub units that receive an "amber" or "red" compliance rating must submit an action plan to HFS detailing how they will address issues identified through the monitoring process.
6. Boards have been reporting their quarterly cleanliness results to HFS since 2006. In most cases, standards have remained within "green" status. The NCSS and monitoring tool have ensured a consistent approach to cleaning and cleaning methodology across Scotland and have provided reassurance to patients, staff, visitors and the general public. The latest report (2 March 2011) confirmed national compliance of 95.3% in the period October to December 2010.
7. The HAI Task Force requested HFS to administer an independent audit of NCSS systems and processes to ensure compliance and promote confidence in the quarterly results produced by boards. Two independent audits have been completed, one in 2008/2009 and the other in 2009/2010. Both provided recommendations that have been implemented across NHSS through the HFS Domestic Advisory Group.
8. A key recommendation has been for HFS to strengthen the monitoring tool to ensure a more consistent approach and to further promote confidence in the standards being reported. This work is ongoing.
9. The independent audits have raised staff and public awareness of the importance of the NCSS. They have also ensured that boards move towards a culture of continuous improvement and have provided a conduit for strengthening of the NCSS and the monitoring tool to ensure stricter compliance.
10. In 2007, the National Patient Safety Agency ( NPSA) developed a National Colour Coding Scheme for cleaning materials in England and Wales. The HAI Task Force recommended that the scheme be adopted as standard throughout Scotland to improve the safety of hospital cleaning, ensure consistency throughout Scotland, England and Wales and providing clarity for staff. HFS was asked to implement the system throughout NHSS.
11. All materials and equipment (such as cloths, mops, buckets, aprons and gloves) were colour coded during 2008. HFS provided training and training manuals for all boards and, by the end of 2008, the whole of NHSS had implemented the system.
12. Introduction of the colour code system has raised awareness of the importance of reducing cross contamination and has improved cleaning practice.
Action area 5.2 Promote specification of new builds as fit for purpose for HAI prevention
1. This has been superseded by action area 5.9.
Action area 5.3 Innovations research project - phase II
1. During 2009, HFS undertook a study into the effectiveness of micro fibre and the use of a novel copper compound in the reduction of environmental contamination. This revealed a reduction in physical contamination of 58%. The study also identified a residual effect of the copper compound, which was not measured. The study report made a number of recommendations, which included a further study into this residual effect, the cost of implementing the system across NHSS and the effectiveness of the copper compound on spores retained within the micro fibres.
2. A phase II study project initiation document ( PID) has been developed and further discussions involving key national stakeholders are ongoing to agree next steps. This work will be included in future HAI Task Force deliverables.
Action area 5.4 Education and training frameworks for all staff within facilities services
1. HFS, working in partnership with NES, introduced a training and education framework for domestics and housekeepers in 2007, along with a manager's guide for implementation. The framework provides individuals with a workbook of basic tasks which includes infection control, health and safety and cleaning task knowledge and evaluation. Staff have to complete all of the sections within the workbook, which is assessed by their supervisors or managers and which ensures a consistent basic entry level of education, learning and development across NHSS for domestics and housekeepers.
2. Due to the success of the framework, the HAI Task Force asked HFS to provide similar workbooks for all staff groups within estates and facilities. To date, workbooks and managers' guides have been produced for domestic staff and housekeepers, catering staff, porters, security staff, linen services and estates staff, all of whom are now referenced to the Healthcare Support Workers Induction Programme. The domestic and housekeepers framework will undergo a revision during 2011.
Action area 5.5 Study programme on cleaning regimes
1. HFS undertook a cleaning innovations study into adenosine triphosphate ( ATP) bioluminescence sampling to identify if the system could be used by NHSS as a further step to check that "clean is clean". The study was undertaken by NHS Greater Glasgow & Clyde.
2. A study took place in NHS Lothian into the microbiological evaluation of dry steam vapour ( DSV) performance in the terminal clean of patient beds and isolation room fixtures and surfaces and to evaluate the performance of the OspreyDeepclean ( ODC) system as both a cleaning and decontamination method. This was carried out quantitatively by microbiological measures for both aerobic and anaerobic bacteria with specific measures for Clostridium difficile spores. The study was undertaken using the ODC ProVap steam cleaning system and employed the standard operating procedures specified by the company for the respective equipment cleaned and reported in the study.
3. HFS and NHS Greater Glasgow & Clyde undertook a partnership study during 2010 which has been identifying the effect of "target" cleaning agents and their effectiveness on reducing environmental contamination. A study report is due in March 2011.
4. HFS is presently working in partnership with the Royal Liverpool Hospital to investigate the effectiveness of hydrogen peroxide misting on the reduction of environmental contamination following normal cleaning procedures. This study will take place during 2011/2012.
5. HFS has published a research report pulling together the available information on light-based technologies for the disinfection of air. A report on disinfectants for water systems is also in production.
Action area 5.6 A housekeeping pilot scheme hosted by HFS
1. A ten-week study was undertaken in NHS Ayrshire & Arran looking at the role of the housekeeper, the benefits of such a role and the cost of implementation across NHSS. The study identified that specific duties for the ward housekeeper increased standards of cleanliness in the ward, clinical staff time to care and patient satisfaction and confidence.
2. The outcome of the study has been reviewed by the Scottish Government and agreement has been reached with the HAI Task Force that the findings should be used to inform an ongoing review of the healthcare support worker role. Representatives from HFS and the NHS board in which the study was carried out are members of the healthcare support worker working group.
Action area 5.7 Develop training package for ICTs specifically around areas of mechanical services such as ventilation, water systems
1. This has been superseded by action area 5.9.
Action area 5.8 Develop training package for HAI guidance for NHS boards
1. This has been superseded by action area 5.9.
Action area 5.9 Development and implementation of an estates monitoring tool
1. This project, which set out to deliver an audit monitoring solution for the NHSS estate, superseded action areas 5.2, 5.7 and 5.8 of the HAI Task Force Delivery Plan.
2. HFS commissioned a working group with representatives from all NHS boards, which was split into subgroups to carry out various areas of work. An interim domestic monitoring tool (which includes estates-related issues) was rolled out across NHSS from April 2010. Boards are providing HFS with monthly results which are being investigated by the Systems Integration Board for accuracy. This process will remain in trial until there is confidence in the data being reported and will then be merged with the quarterly cleaning compliance reports.
3. An estates monitoring tool will provide boards with an accurate account of the legislative and physical standards of the estate and will ensure that high priority HAI-related works are completed in a timely manner in accordance with the rectification requirements laid down within the estates monitoring protocols. This is expected to be rolled out across NHSS by end March 2012 and will be included in future HAI Task Force deliverables.
Action area 5.10 Facilities support team
1. HFS is presently recruiting a Facilities Support Team that will have four key strategic activities:
- working with boards to resolve issues raised by the HEI audit team timeously and effectively with minimal service and media impact;
- strengthening reporting and monitoring procedures for cleaning monitoring to give the Scottish Government further confidence in the monitoring results produced by boards across catering, domestic and estates issues and into new areas in the future;
- developing and implementing an estates monitoring tool across NHSS to provide appropriate reports to the Scottish Government and to monitor results being produced by boards; and
- developing and delivering a National Catering Cleanliness and Safety System, as required by the HAI Task Force, with robust independent monitoring arrangements to mitigate against the high-impact, high-likelihood risks that are associated with food hygiene.
2. The Facilities Support Team will also provide training and support to boards, particularly around a consistent approach to monitoring and the application of the national cleaning standards.
ADDITIONAL DELIVERY AREAS
Action area 6.1 SIRN research and support
1. Using data obtained from a short web survey in 2008, SIRN was able to form an historical picture of HAI-related research in Scotland. Using this information, SIRN has focused on specific areas of research where gaps in evidence existed. In its 2008/2009 funding initiative, SIRN offered support to 11 projects around Scotland to address priority areas of research in HAIs (examples are shown in Box 1). The research involved both new and experienced researchers in a range of laboratory/clinical/behavioural projects funded by awards of between £1218 and £125 351.
Box 1. Examples of key SIRN projects, 2008-2011
- Use of hand-held computers to determine the relative contribution of different cognitive, attitudinal, social and organisational factors on healthcare workers' decision to decontaminate hands.
- Management of UTI symptoms in patients attending community pharmacies.
- MRSA screening: retrospective analysis of 15 years' data.
- The effectiveness of admission risk assessment and pre-emptive cohorting of high-risk patients to control MRSA.
2. This translational research will fill in some of the evidence gaps that exist within current clinical practice and HAI prevention. Evaluation of reports on completed projects indicates results that will be of use to the HAI community both directly and in future publication.
3. Since 2008, SIRN has introduced seven special interest subgroups (antibiotic prescribing, behavioural aspects of infection control practice, building research into infection control nursing, Clostridium difficile, diagnostic testing, MRSA, and Streptococcus pneumonia), each acting as a hub for networking and providing support for researchers.
4. In 2009, SIRN supported an application for a UK Clinical Research Collaboration ( UKCRC) initiative entitled "Knowledge mobilisation for improving prevention and management of infection." Although the application was unsuccessful, it highlighted some of the issues involved in Scottish groups applying for UK funding.
5. SIRN has hosted events throughout the country to support the above topics (as well as those of general interest) which provided an opportunity for colleagues from multi-disciplinary backgrounds to increase their knowledge and understanding of issues and research relating to HAI. They also provided an opportunity to network with others from related fields, allowing cross-fertilisation of ideas. Events to date include:
- research update and getting started, Stirling, October 2007;
- developing Scottish priorities for MRSA, Glasgow, April 2008;
- antibiotic use: making the best of what we have, Glasgow, June 2008;
- Clostridium difficile, Edinburgh, September 2008;
- antimicrobial pharmacy issues, Glasgow, January 2009;
- invasive fungal infection: today and tomorrow, Glasgow, June 2009;
- Royal College of Physicians of Edinburgh hot topic symposium - healthcare associated infection (run jointly with SIRN), Edinburgh, February 2010;
- grants, money and career: what every new researcher needs to know (run in collaboration with the Infectious Disease Research Network and Medical Research Council), Clydebank, February 2010;
- patients' journey: missing data, behavioural research event, Perth, April 2010;
- World Pneumonia Day: perspectives on pneumonia and pneumococcal disease, Glasgow, November 2010;
- European Antibiotic Awareness Day symposium at the Federation of Infection Societies Annual Meeting, Edinburgh, November 2010; and
- diagnostic and therapeutics event (run jointly with the Scottish Microbiology Society), Glasgow, February 2011.
6. In 2010, SIRN launched the SIRN seminar sponsorship programme to promote talks on HAI-related topics in departmental seminar programmes throughout Scotland. Topics were relevant to the aim of SIRN, which is "to contribute towards the prevention and control of HAIs".
7. SIRN has also had representation at several events in Scotland, including:
- Cleaning up infection control - spreading good practice study day, Hamilton, 2008;
- Staphylococcus aureus bacteraemia, Dunblane and Clydebank, 2008;
- improving quality and safety to prevent HAI in NHS Scotland ( CDAD/ SAB), arranged by HPS, Clydebank, 2009;
- infection prevention and control: champions challenged!, NHS Grampian study day, Aberdeen, 2009;
- healthcare associated infections - past, present and future, organised by HPS, Clydebank, 2009;
- Scottish Microbiology Association spring 2010 meeting, Aviemore, 2010;
- Scottish School of Primary Care Annual Conference, Crieff, April 2010; and
- NHS Grampian cleanliness champions conference, Aberdeen, May 2010.
8. Underpinning the network has been the SIRN website, which has established itself as a rich resource for researchers in Scotland, providing information on relevant funding opportunities, events and current job vacancies and links to other useful websites. Members have access to the database itself, which in turn provided access to the members and their interests in HAI-related research, and receive emailed updates on any relevant HAI-related initiatives. Network membership continues to increase and currently stands at over 400 active participants.
9. Since 2008, SIRN has worked closely with a number of Scottish and UK organisations. SIRN is represented on the HAI Commodities Steering Group, SAPG, MRSA Screening Study Programme Board, RCPath Infection Research Sub-committee, UK Clinical Research Network ( UKCRN), Microbiology Speciality Group and the Infectious Disease Research Network.
10. SIRN liaised with HPS to maximise the benefit of events and projects and to ensure that infection control nurses and infection control managers were aware of initiatives. SIRN used the NHSS Knowledge Network to allow easy access to steering group documentation and to publicise SIRN events and initiatives.
11. SIRN has interacted with other HAI-related groups such as the Infectious Disease Research Network, National Healthcare Associated Infection Research Network, Scottish Microbiology Society, the Royal College of Physicians (Edinburgh) and SPSP and has acted as an interface between industry, healthcare and academic staff. SIRN has also built good relationships with several pharmaceutical, clinical and laboratory suppliers and involved them in activities, where appropriate.
12. SIRN is currently developing collaborative research with a number of Scottish universities with a view to approaching grant-funding bodies for financial support.
Action area 6.2 HAI Commodities Steering Group
1. The HAI Commodities Steering Group ( CSG) has met on six occasions since its inception. It has hosted two additional meetings to review innovative technologies - a seminar on the subject of textiles in healthcare and one on the topic of disinfection by high-intensity narrow spectrum light. The group co-hosted with the Infection Prevention Society a major one-day conference held in Glasgow in October 2010, the morning session of which examined the adoption of new HAI technologies into the NHS with the afternoon session concentrating on clinical topics and some of the products or technologies developed to address them.
2. Additionally, the group has reviewed hand hygiene products, including methods of evaluation of hand rubs, and examined products that may contribute to the SPSP, including CVC packs and products claiming to reduce the risk of VAP. The group has sponsored two health technology appraisals/evidence notes published by NHSQIS for the Scottish Health Technology Group (the subjects being topical negative pressure and hand-held bladder scanners) and a third submission is in progress. Some sample actions from the Group are shown in Box 2.
Box 2. Sample actions from the HAI Commodities Steering Group
The group has:
- agreed a standardised response to supply enquiries identifying routes to market for HAI products;
- agreed a methodology for the evaluation of new products, utilising the processes of the Health Protection Agency's ( HPA's) Rapid Review Panel;
- reviewed 24 products using the above methodology; and
- established a tracker to review progress against HAI national contracts and related areas.
Action area 6.3 Antimicrobial pharmacist posts
1. Prudent use of antimicrobials has always been a core responsibility of pharmacists. However, increasing AMR and HAIs have resulted in the evolution of antimicrobial pharmacy as a specialist practice over the last 10 years.
2. A combination of local and central funding from the Scottish Government has helped develop a network of these pharmacists within each NHS board to support the implementation of SAPG and AMT objectives.
3. Central funding to support establishment of these posts (announced in CEL 30 2008) will continue in 2011/2012.
Action area 6.4 Additional cleaners
1. In April 2009, the Cabinet Secretary for Health and Wellbeing announced that over £5 million was to be made available in 2009/2010 to support recruitment of additional cleaners for NHSS. The aim of this extra investment was to support boards in ensuring the highest possible standards of cleaning were met as part of the Scottish Government's drive to tackle hospital infections and providing much-needed local employment opportunities for the Scottish economy.
2. Funding at this level was sustained in 2010/2011 and will carry forward into 2011/2012.