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Hand Hygiene Action Plan_Final Draft for IPCG
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Draft v8
DRAFT Hand Hygiene Action Plan - Cardiff and Vale University Health Board
Objective Aim Comment Expected outcome
Completion date
Monitoring Lead Manager
UHB AreaTo design and deliver a hand hygiene communication strategy
To systematically communicate and promote hand hygiene awareness throughout healthcare and community settings in Cardiff and the Vale UHB area.
Hand hygiene is a fundamental component of effective infection control, particularly in healthcare settings where it will contribute to achievement of AQF targets on HCAI
Hand hygiene communication plan
June 2011 Monitoring of agreed actions in communication plan
Director of Public Health
Wider CommunityTo improve hand hygiene in wider community settings
To identify opportunities to improve promotion of hand hygiene with partner organisations, including: Schools Health Protection
Team Environmental Health
Departments Pharmacies
School nurses are a key link with schools
Healthy Schools activities stress importance of hand washing
Public Health Wales Health Protection teams work closely with Local Authority Environmental Health officers to control spread of infectious disease in the community, including via advice on hand hygiene
Better hand hygiene practice in community settings
Will be continual as ongoing
Consultant in Public Health
1
Draft v8
Objective Aim Comment Expected outcome
Completion date
Monitoring Lead Manager
Primary CareAll practices to use the primary care audit protocol produced by the Primary Care Quality and Information Service (Public Health Wales)
Use of the audit tool promoted in all general practices.
Promotion has taken place via the nominated infection control lead in each practice. First round of audit uptake completed.
Further promotion of the audit will take place and uptake re-audited
Snr Nurse Primary care to link with locality leads to promote the initiative
To re identify infection control leads/hand hygiene leads within General Practice.
To recirculate hand hygiene audit tool and summary report to mangers and practice nurses via email
To identify to each organisation that the Hand hygiene module can now be accessed as an individual module and forms the basis of training needed to lead on hand hygiene in the practice
Improvement in number of practices using audit protocol
Re-audit
All organisations to re-identify lead
September 2011
June 2011
June 2011
June 2011
February 2011June 2011
Baseline audit completed.
Repeat audit to be conducted annually.
Senior Nurse for Primary Care
2
Draft v8
To offer training in hand hygiene and the use of the light box to individual organisations in order that they undertake the hand hygiene audit.
ongoing
All practices to utilise the Welsh Healthcare Associated Infection Programme hand hygiene e-learning tool
To pilot the use of the e-learning tool by Infection Control link practitioners (‘Champions’) within each GP practice as a means of disseminating good hand hygiene practice
Uptake will be audited and feedback obtained to determine whether it is a useful tool. If the pilot is successful, use will be promoted more widely through the organisation.
Identify pilot practices by contacting all organisations, asking them to take part. Alternatively identify named organisations in house and follow through with a short meeting, access to the hand hygiene module and access to the light box.
Snr Nurse for primary care to distribute relevant information in a timely manner
Improved hand hygiene practice.
Pilot audit end Jan 2011
June 2011
ongoing
Audit of use of e-learning tool
Senior Nurse for Primary Care
To implement ‘bare below the elbows’ (NHS Wales dress code)
To publicise and promote ‘bare below elbows’ message for all clinical staff and in all clinical area
To promote through the e-learning tool, educational sessions and audit form
All staff in clinical areas to be bare below the elbows
Ongoing Audit of compliance
Medical Director
3
Draft v8
Independent Sector Providers (Nursing Homes/ HM Prison)Objective Aim Comment Expected
outcomeCompletion date
Monitoring Lead Manager
All providers to use the primary care audit protocol produced by the Primary Care Quality and Information Service (Public Health Wales)
Use of the audit tool promoted in all nursing homes and in HM Prison Cardiff.
Promotion has taken place via the nominated infection control lead in each nursing home. First round of audit uptake completed.
Further promotion of the audit will take place and uptake re-audited
Snr Nurse Primary care to link with locality leads to promote the initiative
To re identify infection control leads/hand hygiene leads within nursing homes and HMP Cardiff
To recirculate hand hygiene audit tool and summary report to mangers and practice nurses via email
To identify to each organisation that the Hand hygiene module can now be accessed as an individual module and forms the basis of training needed to lead on hand hygiene in the practice
Improvement in number of practices using audit protocol
Re-audit
All organisations to re-identify lead
September 2011
June 2011
June 2011
June 2011
February 2011June 2011
Baseline audit completed.
Repeat audit to be conducted annually.
Senior Nurse for Primary Care
4
Draft v8
To offer training in hand hygiene and the use of the light box to individual organisations in order that they undertake the hand hygiene audit.
ongoing
All practices to utilise the Welsh Healthcare Associated Infection Programme hand hygiene e-learning tool
To pilot the use of the e-learning tool by Infection Control link practitioners (‘Champions’) within each nursing home as a means of disseminating good hand hygiene practice
Uptake will be audited and feedback obtained to determine whether it is a useful tool. If the pilot is successful, use will be promoted more widely.
Identify pilot organisations by contacting all and asking them to take part. Alternatively identify named organisations in house and follow through with a short meeting, access to the hand hygiene module and access to the light box.
Snr Nurse for primary care to distribute relevant information in a timely manner
Improved hand hygiene practice.
Pilot audit end Jan 2011
June 2011
ongoing
Audit of use of e-learning tool
Senior Nurse for Primary Care
5
Draft v8
To explore the role of nurse assessor teams in supporting infection control in the independent sector
To identify a formal mechanism to support continuing improvement in infection prevention and control practices
The regular oversight role of these teams could be used to promote good hand hygiene practices
Role of nurse assessors in promoting IPC clearly defined
August 2011 Senior Nurse for Primary Care
6
Draft v8
Objective Aim Comment Expected outcome
Completion date
Monitoring Lead Manager
Community NursingTo improve arrangements for infection prevention and control link nurses
To develop a clear system for improving infection prevention and control practice across the service
Link nurses to be re-identified
August 2011 List to be updated annually
Practice Educator for Community Nursing
All lead staff to utilise the Welsh Healthcare Associated Infection Programme hand hygiene e-learning tool
Education and training programmes are in place and improved use of the IPC e-learning package is supported.
All Community Nurses undertake a Mandatory Training Refresher programme annually, recorded and reported through the Electronic Staff Record System.
Improved hand hygiene practice
September 2011
Audit of use of e-learning tool
Practice Educator for Community Nursing
7
Draft v8
To promote appropriate hand hygiene in community setting
Audit tool to be developed to monitor compliance with IPC agenda.
The High Five Campaign (as part of ‘1000 Lives’), was developed with an acute care setting focus, but was launched in the community on 12 May 2010. The initiative is directed at ensuring hand hygiene compliance amongst Community Nurses and raises the profile of infection control. Recommended hand and general purpose wipes are provided for use by all community nursing staff. Timely feedback of HCAI and other surveillance data will also be provided to staff.
Use of audit tool leading will lead to improved hand hygiene compliance
Ongoing Report of audit results
Practice Educator for Community Nursing
To implement ‘bare below the elbows’ (NHS Wales dress code) for all clinical staff
To publicise and promote ‘bare below elbows’ message for all clinical staff and in all clinical area
All staff involved in clinical activity to be bare below the elbows
Ongoing Audit of compliance
Medical Director
8
Draft v8
Objective Aim Comment Expected outcome
Completion date
Monitoring Lead Manager
Hospital CareTo promote the use of the Lewisham hand hygiene audit tool
Monthly audits to be completed by each ward/department.
Monthly hand hygiene audits will be available through the Ward Dashboard.
Hand Hygiene compliance will increase
Ongoing Via Div Quality and Safety meetings and IPC group
Lead Nurse Patient Experience
To conduct IPC validation audits
IPC undertake validation audits within clinical areas on as set out in the IPC AnnualProgramme. 10 areas are audited each month.
Exception report will be produced bi-monthly to highlight the progress.
Compliance audits will demonstrate ward audits accurate
Ongoing Via IPC groupReports also sent to Div Nurses
Lead Nurse Patient Experience
To improve use of hand washing facilities.
Replacing all dispensers for alcohol gel and soap
The soap and alcohol supplier undertook a survey of the requirement across the UHB in Oct/Nov 2010. The new design, which include a drip tray, will protect from accidental splashing into eyes and personal clothing, as wellas protecting the walls and floors from damage. Monitoring of such facilities and user-friendliness will be undertaken periodically by the supplier.
Protection of users and the walls/flooring
June 2011 IPC Senior Nurse will monitor implementation
Lead Nurse Patient Experience
9
Draft v8
Dissemination of Hand Hygiene education
Hand hygiene is promoted at every opportunity during an IPC teaching session
Hand Hygiene is consolidated for all staff who should be complying as well as promoting amongst other colleagues auditing.
All staff should also be able to give appropriate public health advice to inpatients and their relatives
Compliance with hand hygiene policy increases
Current and Ongoing
Lead Nurse Patient Experience
To promote use of the Welsh Healthcare Associated Infection Programme hand hygiene e-learning tool
To propose to the December IPC group meeting that a pilot is conducted of the use of the WHAIP e-learning tool by Infection Control link practitioners (‘Champions’) as a means of disseminating good hand hygiene practice
Uptake will be audited and feedback obtained to determine whether it is a useful tool. If the pilot is successful, use will be promoted more widely through the organisation.
Link Practitioners will undertake standalone module during Link Pract study day
September 2011
Database will demonstrate completion of tool by practitioners
Lead Nurse Patient Experience
To implement ‘bare below the elbows’ (NHS Wales dress code)
To publicise and promote ‘bare below elbows’ message for all clinical staff and in all clinical areas
All staff in clinical areas to be bare below the elbows
Ongoing Audit of compliance
Medical Director
10
