Infection Control Performance Report Dashboard Summary - January 2009
Medical
1
100
2
100
3
100
4
100
5
100
100
100
N/A
100
86
100
100
100
100
100
100
97
100
▲
NIL
100
100
▼
▲
1
NIL
1
80
1
100
◊
NIL
100
67
100
100
100
100
100
100
100
100
100
91
100
99
▲
100
100
100
100
100
100
◊
NIL
100
100
100
100
100
N/A
100
100
100
100
100
100
100
100
▲
1
NIL
1
100
1
100
100
100
98
100
99
99
▲
80
80
100
100
100
100
100
90
100
1
◊
Radiology (All)
100
100
100
100
0
95
▼
100
Diagnostics Totals:
100
100
100
100
0
95
▼
100
100
100
100
100
100
94
100
100
100
100
100
100
100
100
100
100
100
100
100
83
86
94
100
100
100
100
91
100
100
100
100
100
90
100
100
93
100
100
100
100
97
100
98
96
97
97
100
100
▲
40
100
100
95
95
83
▼
NIL
89
100
96
98
97
95
▼
89
100
100
N/A
100
N/A
90
100
90
100
93
100
▼
100
95
85
43
96
100
N/A
50
N/A
100
100
100
89
50
100
100
100
94
57
96
100
100
95
43
96
100
99
88
48
97
A&E
Alexandra Ward
ASU
CCU
Chemotherapy
Endoscopy
Glossop Ward
MAU
Medical Tests
Staples Ward
Medicine Totals:
11
4
1
3
1
1
4
11
4
norovirus
NIL
NIL
▲
Attendance
100
99
97
◊
▼
▼
99.5
99
▲
98
N/A
100
99
▲
▼
▲
▲
▲
1
40
1
75
100
100
67
98.5
▼
100
90
72
100
40
1
83
100
100
100
100
99
▼
100
NIL
▼
1
◊
Cleanliness
score
(see NB. below)
100
1
▲
▼
IC Training
97
99.5
100
100
100
99
99
98
◊
▲
100
100
80
100
60
90
100
1
Cleaning
Urinary
Ongoing
Bideford - Elizabeth
Bideford - George
Bideford - Margaret
District Nursing (All)
Holsworthy Hospital
OPD/MIU (All)
Physio/OT (All)
South Molton Hospital
Therapy Services
Torrington Hospital
Tyrrell Hospital
C/H Totals:
Diagnostics
Combined
score
Reason
Regular
Entire
ward
Ventilated
Ongoing
Bays
(inc.ward
closure)
Peripheral
Ongoing
MRSA
bacteraemia
High Impact Intervention Bundles
Central
Insertion
Community Services
DEPARTMENT
>2days from
admission
Hand Hygiene Surveillance
*Individual score for each
of the 5 Moments of care
Insertion
DIRECTORATE
<2 days
from
admision
Outbreak
No. of days closed
Ongoing
MRSA
Insertion
C diff
Sample taken:
100
100
0
100
▲
◊
▲
▲
◊
◊
▼
Patient Access Supp Serv Outpatients (All)
P.A.S.S Totals:
Surgical
Capener Ward
Day Surgery Unit
ENT OPD
FAU Ward
ICU
KGV Ward
Lundy/Roborough
Recovery (All)
Specialist Nursing
Theatres (All)
Surgery Totals:
Women & Children
Bassett Ward
Caroline Thorpe Ward
Central Delivery Suite
Petter Ward
SCBU
W&C OPD
W & C Totals:
TRUST TOTALS:
1
4
0
11
4
◊
▲
100
▲
▼
▲
92
100
100
92
100
96
91
91
96
94
93
93
▲
N/A
100
88
100
100
N/A
100
100
100
100
100
100
78
100
100
100
100
100
78
100
100
100
100
100
100
100
92
100
100
N/A
88
100
95
100
100
100
▼
100
98
100
95
97
97
97
94
98
96
97
96
96
▲
↑
↑
↑
↑
↑
↑
Trust & Directorate totals refer to combined observations
*Compliance rate for each moment of care to be collected from October 2008
Infection Control Team
Northern Devon Healthcare NHS Trust
▲
100
83
100
NIL
NIL
NIL
100
90
43
67
33
100
100
56
NIL
90
60
NIL
1
100
100
1
NIL
100
100
100
▼ 100
100
100
100
100
80
41
75
▼
◊
100
100
67
NIL
80
100
80
75
100
100
17
◊
100
100
67
▲
90
90
100
80
50
1
NIL
6
6
100
100
◊
99
99
97
99
▼
99
◊
99
97
99
99.5
99
◊
▼
◊
◊
▼
◊
▼
▼
◊
0
100
100
100
88
61
HII ward results refer to the percentage of occasions when every element of the care bundle was met
Trust & Directorate totals refer to the % of wards sending in a return & achieving 100%
Compliance bands for Hand Hygiene & High Impact Interventions:
1
Before patient contact when approaching him/her
<85% achieved
2
Immediately before an aseptic technique
85-95% achieved
3
After exposure risk to body fluids (& glove removal)
>95% achieved
4
5
After contact with patient & his/her immediate surroundings
When leaving after touching object within pt surroundings
no return required
non-return (number of consecutive non-returns shown)
◊
compliance remains the same as previous month
▲
▼
compliance has improved since last month
compliance has fallen since last month
Infection Control Dashboard - January 2009
Number of Clostridium difficile cases by month > 2 days after admission
(Trust Total)
12
2007-08
10
Annual Cumulative Clostridium difficile cases (> 2 days after admission)
(Trust Total)
90
2
1
2008-09
2007-08
2008-09 Plan
2008-09
2008-09 Plan
2008-09 Plan
80
2
70
60
8
2008-09 Plan
50
6
40
30
1
4
20
2
10
0
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Apr
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2007-08
7
8
6
9
5
9
4
10
6
8
4
3
2008-09
8
7
4
5
7
3
1
2
3
4
2008-09 Plan
7
6
6
7
6
6
7
6
6
7
6
7
May
Jun
Apr
Jul
May
Aug
Jun
Sep
Jul
Oct
Aug
Nov
Sep
Dec
Oct
Jan
Nov
Feb
Dec
Mar
Jan
2007-08
7
15
21
30
35
44
48
58
64
72
2008-09
8
15
19
24
31
34
35
37
40
44
2008-09 Plan
7
13
19
26
32
38
45
51
57
64
Total no. of Clostridium difficile cases, > 2 days after admission, plus 'Others'
(Trust Total)
High Impact Interventions Performance
(Trust Total)
14
Feb
79
70
77
<85% compliance
85 - 95% compliance
>95% compliance
100%
2007-08 cases
90%
Percentage acheivement
12
10
8
2008-09 Plan
6
80%
70%
2008-09 Others
2008-09 >2 days
from admission
Apr
May
Jun
Jul
Apr
Aug
May
1 Sep
Oct
Jun
Jul
Nov
Dec
Jan
Feb
2%
24%
26%
5%
6%
6%
10%
7%
50%
40%
78%
77%
76%
70%
63%
77%
67%
10%
0%
Jul-08
Mar
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
5
5
Aug-08
Sep-08
Oct-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Nov-08
Dec-08 Jan-09
2007-08
7
12
8
11
8
13
8
10
12
12
>95% compliance
44
48
64
53
57
59
2008-09 Total cases
11
13
8
7
7
4
2
2
4
5
85 - 95% compliance
7
1
7
4
5
4
5
2008-09 > 2 days from admission
8
7
4
5
7
3
1
2
3
4
<85% compliance
19
13
11
13
20
14
19
2008-09 - Others
3
6
4
2
0
1
1
0
1
1
2008-09 Plan
7
6
6
7
6
6
7
6
6
7
Total number of returns within each compliant band. (Excluding nil returns.)
6
18%
20%
2
0
19%
9%
60%
30%
4
13%
21%
27%
7
48
Dec-08
Mar
76
Jan-09
Infection Control Dashboard - January 2009
Number of MRSA Bacteraemia cases by month
(Trust Total)
2
2008-09
2008-09 Plan
1 2007-08
4
Annual Cumulative MRSA Bacteraemia cases
(Trust Total)
15
2007-08
2008-09 Plan
12
2
3
2008-09
2008-09 Plan
9
2
6
1
1
3
0 0
0
0
0 0
0
0
0 0
0
0
Apr
May
Jun
Jul
Aug
Oct
Sep
Nov
Feb
Jan
Dec
Apr
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2007-08
3
2
0
3
1
0
2
1
0
0
1
2
2008-09
1
1
0
0
0
0
1
0
1
0
2008-09 Plan
1
1
1
1
1
1
1
1
1
1
1
Aug
Oct
Sep
Nov
Jan
Dec
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2007-08
3
5
5
8
9
9
11
12
12
12
13
15
2008-09
1
2
2
2
2
2
3
3
4
4
2008-09 Plan
1
2
3
4
5
6
7
8
9
10
11
12
Hands Hygiene Audit - monthly overall compliance
(by Directorate)
Hands Hygiene Audit - monthly overall compliance
(by Staff Group)
100%
100%
95%
95%
90%
90%
85%
85%
80%
80%
75%
75%
70%
70%
65%
65%
60%
60%
55%
55%
50%
50%
Aug 08
Jul 07
Staff
1
Jul
Jun
May
Aug 07
Sep 08
1
Doctors
Oct 08
Nursing
Nov-08
Other
Dec-08
Jan-09
Sep 08
Oct 08
Community Services
Patient Access Supp Serv
Trust
Trust
Directorate
Nov 08
Diagnostics (new from Nov)
Surgical
Jul 07
Aug 07
Sep 08
Oct 08
Nov-08
Dec-08
Jan-09
Aug 08
Sep 08
Oct 08
Nov 08
Dec 08
Doctors
78%
79%
86%
84%
85%
85%
90%
Community Services
97%
95%
97%
97%
98%
99%
Nursing
95%
97%
95%
98%
99%
97%
98%
Diagnostics (new from Nov)
0%
0%
0%
100%
100%
95%
96%
95%
Jan 09
Other
94%
90%
91%
92%
95%
97%
92%
Medical
94%
95%
94%
95%
Trust
92%
92%
93%
94%
95%
95%
96%
Patient Access Supp Serv
100%
96%
95%
87%
Surgical
86%
93%
91%
93%
89%
93%
Womens & Children
91%
95%
94%
100%
98%
97%
Trust
92%
93%
94%
95%
95%
96%
Dec 08
Medical
Womens & Children
Jan 09
5 MOMENTS HAND HYGIENE BREAKDOWN
JANUARY 2009
Compliance with the 5 Moments of Care ‐ Hand Hygiene Surveillance
(Per Directorate)
100%
100%
95%
95%
90%
90%
85%
85%
80%
80%
75%
75%
70%
70%
65%
65%
60%
60%
55%
55%
50%
Moment 1
Community Services
Moment 2
Diagnostics
Moment 3
Medical
Moment 4
Surgical
Moment 5
Women & Children
Compliance with the 5 Moments of Care‐ Hand Hygiene Surveillance
(Per Staff Category) 50%
Moment 1
Moment 2
Doctors
Nursing
Trust
Moment 3
Moment 4
Housekeeping
Moment 5
Other
Trust
Moment 1
Moment 2
Moment 3
Moment 4
Moment 5
Moment 1
Moment 2
Moment 3
Moment 4
Moment 5
Community Services
100%
100%
98%
100%
99%
Doctors
81%
90%
92%
93%
95%
Diagnostics
100%
100%
100%
100%
0%
Nursing
97%
100%
98%
100%
99%
Medical
89%
100%
96%
98%
97%
Housekeeping
97%
100%
98%
100%
99%
Surgical
91%
91%
96%
94%
93%
Other
92%
100%
100%
91%
85%
Women & Children
98%
100%
100%
97%
95%
Trust
94%
98%
96%
97%
96%
Trust
94%
98%
96%
97%
96%