NLG(14)444. DATE OF MEETING 28 October Trust Board of Directors Public REPORT FOR. Infection and Prevention Control Team REPORT FROM

Transcription

1 NLG(14)444 DATE OF MEETING 28 October 2014 REPORT FOR Trust Board of Directors Public REPORT FROM Infection and Prevention Control Team CONTACT OFFICER Neil Gammon Non-Executive Director/Dr Mark Withers Medical Director SUBJECT Infection and Prevention Control Committee minutes September 2014 BACKGROUND DOCUMENT (IF ANY) NLG(14)400 IPCC Highlight report submitted to September Trust Board REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Ratified by the Infection and Prevention Control Committee EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED Ensuring effective monitoring of Infection prevention and control ACTION REQUIRED BY THE BOARD To note the contents of the minutes

2 INFECTION PREVENTION & CONTROL COMMITTEE Minutes of the Infection Prevention & Control Committee held on 25 th September 2014 at pm in the Modular Meeting Room SGH with vtc to the Small Meeting Room DPoW PRESENT: Mr Neil Gammon Andy Karvot Debbie O Toole Dr Karen Dunderdale Dr Mark Withers Dr Peter Cowling Dr Tony Vicca Greta Johnson Kathryn Helley Linda Taylor Paul Kirton-Watson Ruth Kent Victoria Grainger Viv Duncanson Laura Owen Non-Executive Director (Chair) Consultant Antimicrobial Pharmacist Head of Occupational Health & Wellbeing Chief Nurse Medical Director Consultant Microbiologist Consultant Microbiologist Community Services Infection Control Nurse Deputy Director of Performance & Asst Trust Secretary Health Protection Nurse Specialist, Public Health England Associate Chief Nurse Head of CT/MRI Senior Healthcare Scientist Assistant Senior Nurse, Infection Control/Assistant DIPC PA to Medical Director (minute taker) 1. Apologies for Absence Apologies were received from the following; Dr Jim Whittingham Karen Jackson Wendy Booth Chairman Chief Executive Director of Clinical and Quality Assurance 2. Minutes of the previous meeting The Committee ratified the minutes of 21 st July Neil Gammon wanted to address the various agenda setting concerns raised prior to this meeting; currently Dr Mark Withers, Viv Duncanson and Neil Gammon meet to set the agenda, 2 weeks prior to the meeting. Action: Future agenda call s will be distributed from Laura Owen prior to the agenda setting meetings. The agenda call will include a deadline: items will not be accepted after the deadline. All papers to be submitted to Laura with completed IPCC front sheets which must include meaningful comments. 3. Matters Arising 3.1) Sign off July 2014 minutes & Quoracy Neil Gammon asked whether the Committee agreed that the correct action was taken at the previous meeting; the Committee was not quorate, but decided for the meeting to still go ahead with a view to seeking formal approval for any actions agreed from the now quorate Committee.

3 Agreed: The Committee agreed the appropriate action was taken and approved the actions of the previous meeting. 3.2) Update on the adherence to Antimicrobial Policy (Minute 3.2 & 3.5 refers) Andy Karvot referred to the document distributed prior to the meeting. This paper showed a number of examples where Trust policy is not being complied with. Dr Withers queried what is currently in place. Dr Cowling explained that traditionally on a regular basis, published guidance from professional/specialty societies is taken into account and Trust policy is updated where necessary, invariably in line with national policy. Further discussion ensued, with some anecdotal examples of unauthorised non-adherence to policy cited. It was agreed that Dr Withers would work with Dr Cowling to ensure that either Trust antimicrobial prescribing policy was being adhered to or that appropriate derogations were sought and approved in accordance with an agreed procedure. Action: Dr Withers to provide an update for November IPCC. Andy Karvot raised an additional concern regarding the Nationally mandated Antimicrobial Steering Group which continues to be poorly attended, as this is a Sub-Committee of the board, Andy asked whether this should be brought to the attention of the Trust Board. Action: Dr Cowling, Dr Vicca and Andy Karvot to meet to discuss outside of this meeting. Neil Gammon to add to the highlight report for the Trust Board. 3.3) Protocol for new starters (Minute 3.4 refers) The Committee previously discussed the protocol for new starters particularly with regards to chickenpox vaccines. It has been agreed that we will offer vaccines for chickenpox to all new starters who have not previously been vaccinated. Occupational Health are currently waiting for the Patient Group Directive (PGD) to be authorised through pharmacy before this can be implemented. Action: Karen Dunderdale agreed to hasten the PGD with Pharmacy as they can often take a considerable amount of time to be processed. 3.4) Review of the Do not escalate form (Minute 5.1 refers) Viv Duncanson explained that the proposal to introduce a Do Not Escalate form resulted from some MRSA bacteremia RCA investigations. Dr Withers suggested that it may be appropriate to include this form within the overall Do Not Resuscitate policy. This suggestion would need to go through the Trust Management Board and End of Life (EoL) group for approval. Action: Dr Withers agreed to steer this proposed change through the EoL Care group prior to taking it to Trust Management Board. 3.5) Glove Risk Assessment (Minute refers) The IPCT has produced posters etc. in readiness for the launch of The gloves are off campaign. 3.6) Updated IPCC ToRs The Committee agreed that a sentence should be added under Quorum of the ToR to say that if the meeting is not quorate the meeting can still go ahead but that all decisions would need to be approved subsequently by a quorate IPCC. Action: Laura Owen to update the ToR. Page 2 of 7

4 3.7) Risk Register outstanding items Viv Duncanson met with Jill Mill and updated all the outstanding items highlighted at the previous meeting. 3.8) Intravascular access Dr Cowling explained that this is an additional matter arising which was highlighted in the IPCC annual report. Within the report it is discussed losing a key member of staff from intravascular access, which is going to affect the ability to insert PICC lines which will cause a significant risk to patients and the Trust for MRSA bacteremia. Dr Dunderdale agreed it is a significant risk to the organisation that we are seeing the invasive devices team ebb away, the existing team looks in addition to placing PICCs also oversee the intravenous follow up care. Viv Duncanson advised that a replacement nurse has been appointed but does not have experience in insertion of PICC lines, it generally takes 6 months to become competent in the insertion of PICC lines. Dr Vicca suggested staff grade anesthetists could be considered as an option. Action: Dr Withers, Dr Dunderdale and Viv Duncanson to meet to discuss further, with an update to the November IPCC. 4. Items for Discussion 4.1) MRSA Screening Viv Duncanson presented a DoH paper containing modified admission MRSA screening guidance. The DoH and the Antimicrobial Resistance and Healthcare Associated Infection Advisory Committee (ARHAI) have asked us to review our policy. The advice is to discontinue screening all patients on admission and to only screen patients admitted to high risk units and all persons previously identified as being at risk for MRSA. Viv Duncanson presented an updated MRSA policy to reflect this advice. Action: The Committee agreed for NLAG policy to be distributed for any final comments with a 2 week deadline. The team will then launch the policy after the deadline for comments. 4.2) IPC training stats Viv Duncanson referred the Committee to the IPC training statistics distributed. This will become a standing agenda item. 4.3) High risk infection patients (VHF) Viv Duncanson explained that this item was originally added to the agenda regarding the potential purchase of a pod to be used in the case of presentation of a patient with high infection risk however this has been overtaken by a recent potential case review at SGH. Viv referred the Committee to the Ebola GAP analysis / action plan and letter distributed with the meeting papers. Most of the issues highlighted in the action plan will be discussed in the Ebola debrief meeting which is being arranged following the suspected Ebola case with Dr Withers taking the lead. NB The case was confirmed as malaria, but the presentation and subsequent actions has allowed the Trust to test preparedness for Ebola. Action: Feedback from Dr Withers from the Ebola de-brief meeting to be added to the November IPCC agenda for discussion. Page 3 of 7

5 4.4) 6 monthly progress reports for; Infection Control Annual Progress Viv Duncanson referred the Committee to the annual progress report distributed with the meeting papers; the Trust is currently waiting for a revised version of the hygiene code before review of this item. The Trust have achieved the targets for quarter 1 for the C.difficile CQUIN. HCAI development plan Viv Duncanson advised that we are on track with the majority of the actions. She reported that she has developed a tool to investigate Hospital Acquired Pneumonia and is awaiting appropriate clinician lead here through the M&M group. Hospital at home is currently rated amber and the Committee agreed to transfer this action to the COO s area. Action: Viv Duncanson to Karen Griffiths to advise that the action concerning the hospital at home is being removed and give a hand over. The Continence group is making good head way. The WHO guidance, use of soap and alcohol rub is complete and the action can be made green. The SharePoint action is also complete and can now be made green. Action: Laura Owen to add HCAI development plan for January as an agenda item with regards to input from committee members for the 2014/15 plan. 4.5) Annual International Infection Control week October 2014 Viv Duncanson explained that during Infection Control Week, commencing 14 October 2014, the IPC team plan to use concentrate on cleaning of equipment by use of ATP swabs making the invisible visible / how clean is your kit and we are not too posh to wash are strap lines that will be used.. Various other activities planned to raise awareness including competitions. 4.6) Removal of Penicillin Allergy Labelling Andy Karvot referred the Committee to the document distributed with the meeting papers. Andy explained that it was agreed at the July IPCC meeting for this to be discussed at the November meeting however Andy would like comments from the group whilst it is in draft so that it can be discussed at the November meeting. He has concerns as to the risks such a policy may pose to the Trust and these need to be properly explored by expert members of the IPCC. This will also need to go to the Medical Records Committee (MRC) as well as Safer Medications and Medicines Management Team. 4.7) NLaG Antimicrobials Action Plan Andy Karvot advised that this is the action plan from the Antimicrobial Steering Group which has already been distributed to the Committee. Andy has received comments from Dr Withers. Action: Andy will review and update the NLaG Antimicrobials Action Plan based on comments received and report back to IPCC in November ) Meropenem Snapshot Audit Andy Karvot explained that it was noted at the Trust Board that this Trust is the second highest user of carbapenems within the Yorkshire and Humber Region, when usage is adjusted for size. However, the results of the audit show we are using carbopenems particularly meropenems accordingly and appropriately. Page 4 of 7

6 Action: Neil Gammon to add to the highlight report for the Trust Board. 4.9) AMU/CDU Rapid Cycle Antibiotics Prescribing Audit Cycle Andy Karvot explained in their present format, these audits this did not appear to have the desired effect on compliance with national and Trust standards for antimicrobials prescribing. Professor Sewell had suggested superimposing doctors work rotas on the run-charts for the audit results to try and identify those doctors who are not prescribing to standards. A trial of the modified process is to begin in October, Andy has discussed with Mr Ashaolu who felt that 100% compliance will not be achieved with Trust treatment sheets in their current format and that they require a dedicated antimicrobials prescribing section, which Andy will explore. Action: Andy Karvot to discuss with Mike Urwin, Chief Pharmacist and the safer medication Committee to make the changes to prescription documents. 4.10) Monthly SSTF Antibiotic Prescribing Audits Andy Karvot explained that the July data shows that at SGH, compliance with antibiotic prescribing standards continues to improve, but at DPoW standards have dropped. Andy asked the Committee to note that there appear to be differing standards between the sites. Dr Dunderdale and Dr Vicca asked how there can be such a high percentage of unidentified prescribers. Andy explained that this was due to illegible signatures without names underneath in capitals and the recording of on-call bleep numbers passed from person-to-person was also causing an issue. These issues will be rectified once electronic prescribing is in place. 4.11) Antimicrobials Prescribing Strategy Discussed within agenda item Standing Items 5.1) MRSA Action Plan Action: Viv Duncanson to update Do Not Escalate to say that it has gone to the EoL Group 5.2) C Difficile Action Plan Viv Duncanson advised we have 2 C.diff DIPC review meetings outstanding which are currently being arranged by Laura Owen. The Trust have had 9 hospital acquired C.diff cases, of the 7 DIPC reviews that have been held, 6 were not preventable, and only 1 case was preventable. 5.3) CPE Action Plan Viv Duncanson advised that all actions are now complete and implemented. Numerous training sessions were being carried out. Action: To remove as a standing item. Dr Dunderdale and Neil Gammon to take the CPE plan to the Trust Board to advise of sign off. 5.4) Infection control audit challenge 5.4.1) FLO tool (front line ownership) Viv Duncanson explained that this is a summary of each ward with months and overall scores. The audit looks at 10 sections of infection prevention practice. The new FLO tool was launched in Page 5 of 7

7 April 14 and gives more meaningful scores as well as a more thorough audit. From September onwards nil returns will not be tolerated and will be escalated. The audit is a quite extensive selfaudit but for those areas that are scoring consistently high, it has been agreed they can go to quarterly self-auditing, subject to approval from Viv Duncanson and the relevant Head of Nursing ) Hand hygiene spreadsheet Viv reminded the Committee that any failures need escalating by the matrons to Laura Owen in order that the zero tolerance policy (letter from either the Chief Nurse or Medical Director and 1:1 training with an IPCN can kick in. It was believed that many failures are not currently being escalated to the Medical Director ) 5 moments hand hygiene audit Viv advised that there have been a couple of nil returns which already get reviewed at NMAF. Viv informed that Laura Owen has only received 1 hand hygiene escalation from Paediatrics. Action: Dr Dunderdale to pick up with HoN to escalate any hand hygiene failures to Laura Owen Action: Training stats to be added to future agendas under ) Update Site Specific Groups 6. Policies/Items for ratification 6.1) Derogation of Cath Lab at SGH Dr Vicca explained that this is regarding a sink in the Cath Lab at SGH. He went on to outline his concerns. These were agreed by the Committee who asked that the derogation be reworded to reflect the position. Action: Viv Duncanson to discuss with Heidi Metcalf and re-circulate to the Committee for any final comments and ratification. 7. Policies/items for Ratification 7.1) Tuberculosis Policy Policy still be reviewed. 7.2) SOPs from ITU at SGH Document not ready for approval 7.3) MRSA Policy Already discussed and agreed 8. Trust Quality Development plan IPCC oversight actions Kathryn Helley referred the Committee to the Trust Quality Development Plan which was distributed with the meeting papers. This has subsumed the Keogh plan. She explained that the plan highlights things we are not doing, however this is now a fairly old paper, an updated version will be going to the Trust Board on Tuesday. The plan is mapped to relevant Sub-Committees and at this point in time there are no actions that sit under the remit of the IPCC. Page 6 of 7

8 Action: Kathryn Helley to provide a copy of the updated paper in readiness for the November IPCC. 9. IPCC Annual self-assessment Greta Johnson updated the IPCC Annual self-assessment whilst at the last meeting, however as the meeting was not quorate it was agreed to bring the updated self-assessment back to this meeting for final sign-off by the Committee. Action: Laura Owen to update the IPCC self-assessment, with the action agreed at today s meeting to now go out with an agenda call for additional items prior to the agenda setting meeting. Action: Any further comments or actions required to forward to Laura Owen for formal sign off at the November meeting. 10. Highlight Report for the Trust Board Neil Gammon to forward the highlight report to Laura Owen for the Trust Board 11. Review of Action Log The Committee noted several updates to the action log were required. Action: Laura Owen to make the necessary amendments and circulate the amended action log accordingly. 12. Items for Information 12.1 ICC Group Minutes DPOW 12.2 ICC Group Minutes SGH 12.3 DPOW C.diff Action Group minutes 12.4 SGH C.diff Action Group minutes 12.5 SGH and DPOW C diff Action Group Action Plans 12.6 Antimicrobial Steering Group Minutes 13. Any Other Business None raised 14. Date & Time of Next Meeting: Date: 17 th November 2014 Time: hrs Venue: DPoW, West Arch Boardroom vtc to SGH Modular Building Page 7 of 7