NHS GRAMPIAN Infection Control Committee

NHS GRAMPIAN Infection Control Committee Minutes from meeting held on 26 January 2016 The Conference Room, MacGillivrey Centre, Aberdeen Maternity Hospital 11.00 13.00 Present: AC Amanda Croft (Chair), Director of Nursing and HAI Executive Lead for NHSG PEH Pamela Harrison, Infection Prevention & Control Manager CMcQ Caroline McQuillian, Associate Director of Nursing (Acute) JA Jane Adam, Public Forum Representative LM Leonora Montgomery, Public Forum Representative AB Audrey Bell, Acting Head of Facilities for NHSG BP Ben Parcell, Infection Control Doctor / Medical Microbiologist AMK Anne Marie Karcher, Infection Control Doctor / Medical Microbiologist DW Diana Webster, Consultant in Public Health Medicine MY Mandy Young, Operational Support Nurse Manager, Mental Health Services (attended for Jenny Gibb) RAB Roy Browning, Senior Infection Prevention & Control Nurse KDW Karen Wares, Nurse Consultant (HAI) AMcK Anne Mckenzie, Service Manager / Adults / AHP Lead for Moray CHSCP JW Juliette Watson, Dectontamination Lead for NHSG GB Gladys Buchan, Operational Lead Nurse, Aberdeenshire Health & Social Care Partnership FMc Fiona McDonald, Antimicrobial Pharmacist CL Carol Low, Patient Safety Co-ordinator (attended for Fiona Mitchelhill) AS - Anneke Street, PA to Infection Control Manager (Minute taker) Item Subject Action to be taken and Key Points raised in discussion Action 1 Introduction and Apologies Apologies were received from : Nick Fluck (NF) Gillian Macartney (GMac) Alexander MacKenzie (AM) Julie Warrender (JWa) Heather Macrae (HM) Amanda Croft asked for everyone to introduce themselves as new members have joined the Committee 2 Minutes of last meeting 10 November 2015 The minutes from 10 November 2015 were ratified by the Committee with no amendments. AS 3 Matters Arising Item 3.1 Equipment Cleaning Implementation Group Update PEH informed the Committee that this Group no longer exists and the work will be taken over by the reorganised Decontamination Group. This includes the Bed Response Team SBAR and NHS Grampian A Z document. 1

3 Matters Arising cont. AB added that the Roles and Remit paper for the new Group had been circulated for comments on 20 January 2016 and the first meeting of the revised Group should take place late February 2016. The Group will now include representation that can advise and support on all aspects of medical devices, patient reusable equipment and reusable medical devices. All these sub groups will sit under the umbrella and report to the Decontamination Group AC decided that the NHS Grampian Infection Control Committee would revisit and approve the SBAR submitted for the Bed Response Team. This is to be emailed to all Committee members for their perusal. An update from the Decontamination Group is to be added to the agenda for the next meeting. AS AS Item 3.2 NHSG A Z Update Preston Gan submitted an update to the Committee for information. The A-Z document now includes colour coding for staff groups and is being worked on with Corporate Graphics at present to ensure a workable version can be uploaded to the intranet. AC asked for an update from Preston for the next meeting. Preston Gan Item 3.3 ICC Reporting Arrangements / Membership Interesting feedback was received from the paper that PEH submitted to the Committee at the November meeting. The majority of the comments were surrounding the new Decontamination Group structure and were favourable. This document is progressing. A piece of work is also needed surrounding attendance at the Infection Control Committee. PEH and AC will discuss AC / PEH 4 Standing Items Item 4.1 Sector Reports Acute CMcQ spoke to the report and explained that the risks noted were performance related against the HAI Standards. All risks were noted on DATIX and were being progressed accordingly. Progress Against Areas of Concern Previously Reported 2 a) Medium no programme of cleaning for treatment room couches This continues to be an issue and has not yet been progressed, CMcQ will address this and is working with the manufacturers regarding cleaning instructions / guidance 2

4 Standing Items cont The performance review process has been changed and risks will be discussed and scrutinised Issues surrounding Personal Protective Equipment (PPE) continue to be a challenge with regard to education and procurement. AC replied that this risk belongs to Annie Ingram and has spoken with her in the past. AC will contact Annie Ingram again and suggested that an overall PPE plan was required. AC KDW commented that face fit testing had been deemed to be a priority and therefore this had been progressed first. Education is always a difficult task as staff are unable to be released from clinical areas to attend in many cases. AC felt that there was little movement with this and would discuss the risk with high level nursing staff and the Infection Prevention and Control Team to find a way forward KDW and BP offered to pull together a PPE Plan for the next Committee meeting. AC agreed this was a good idea AC KDW / BP KDW also touched on risk number 11 elearning Compliance and asked whether the issues surrounding managers being able to pull reports from the AT Learning system was resolved. CMcQ replied that she would be able to confirm this after a meeting being held that afternoon. Aberdeenshire New Areas of Concern 1 a) High HAI Adverse Event GB explained that a patient had been admitted with diarrhoea and abdominal pain and that due to Trakcare being inactive and the GP letter not including relevant information, staff were unable to ascertain that there may be a possible Clostridium difficile infection and did not alert their Infection Prevention and Control nurse timeously. The IPC nurse accessed ICNet, informed the relevant parties and provided information. Senior staff and Janice Rollo visited the ward and interviewed the Senior Charge Nurse and Staff Nurse. The patient s care record and related documentation was reviewed. A timeline was produced and an SBAR completed with recommendations. An improvement plan has been drawn up so that similar events will not occur again. This information was shared with higher management within the Shire. Progress Against Areas of Concern Previously Reported 2 a) High Level of HAI Activity within Community Hospitals All environmental audit results have now been collated and unfortunately 90% compliance was not achieved. This has been discussed at the local HAI Group meeting and during the next round of audits in February / March an improvement plan will be worked to instead of the audit tool. These results will be collated by the end of March. 3

4 Standing Items cont AC asked who was monitoring these results. GB replied that this was fed back via the HAI and Patient Safety Groups and GB herself feeds back to the Area Managers. 2 b) Hand Hygiene Opportunities for Patients and Visitors This is in the final stages of completion and has been undertaken in relation to the HEI recommendation for best practice offer the opportunity for hand hygiene to patients at mealtimes or when using the toilet An initial 80% response has been collated from Junior and Senior Charge Nurses which show there are good areas of practice surrounding this. 2 c) Staff Education The process of pulling mandatory education figures from the AT Learning system is still an issue. There has not yet been an effective process identified. Areas of Achievement / Good Practice There has been effective collaboration with Social Work and Care Home Manager who are now HAI Group members. This has built an important rapport and provides increased confidence. RAB suggested that the NHS Grampian Health Protection Team may like to be kept informed of work being undertaken with care homes and social work and the contact for this would be Jayne Leith. Aberdeen City CHP Unfortunately no one from Aberdeen City was able to attend the meeting but a report was provided for the Committee to read AC has some questions and will approach JWa herself to discuss AC Facilities New Areas of Concern 1 a) High Inappropriate standard of refrigeration equipment in some ward kitchens AB reported that this has come from an EHO report as inspectors are now visiting ward kitchens. The standard of some refrigeration has been picked up due to the fridges being household appliances rather than industrial. An SBAR has been submitted through Occupational Health and Safety, a risk has been noted on DATIX and the situation has been escalated to the appropriate people. CMcQ asked whether this was a risk across NHS Grampian and AB replied that it was. All relevant fridges need to be replaced and a report has been sent to Garry Kidd with regards to financing the work. AB also raised the issue of a flushing regime. Recently there have been incidents within closed parts of the hospitals. When a ward or area is closed the Estates Department are not always being made aware and the issue occurs where there is no flushing regime being performed in these areas. Estates must be made aware of any areas closed. If an area is to be used as a standby then procedures need to be put in place for safe usage. AC offered to raise this with the Senior Executive Team where is can be discussed. DW suggested feeding into Civil Contingencies also. AC 4

4 Standing Items cont. Moray (CHSCP) Progress Against Areas of Concern Previously Reported 2 a) High Annual Environmental Audits AMcK reported that unfortunately the local audits have slipped slightly. A continuous programme of visits to all hospitals is underway with previous action plans being scrutinised but there is still some concern regarding the level of knowledge within the auditing team. 2 b) High Failed Hand Hygiene Audit A failed hand Hygiene audit within Seafield Hospital has resulted in a Problem Assessment Group (PAG) meeting taking place. A reaudit will be completed by the Infection Prevention and Control Team In February. Areas of Achievement / Good Practice a) Stephen Hospital is continuing the process of carpet removal from their ward areas however funding and the closure of beds whilst carpets are removed needs to be discussed further. b) The SITREP which includes infection related issues and is available to most Community hospitals on a daily basis is helpful AC asked how the performance framework was achieved within Moray CHSCP. AMcK replied that this has still to be worked on and that she is keen to have readily available data to view. JA stated that she was worried regarding the subject of failed Hand Hygiene audits / general Hand Hygiene being raised so often within the sector reports. She felt that the gelling stations / machines were perhaps not visible enough to staff and patients and therefore not being used as they should be, KDW replied that unfortunately all the machines are coloured white which does not aid their visibility but the company could be approached regarding more visible signage AC asked why this had not been fedback to National Procurement and KDW confirmed that it had but the product had still been brought in. KDW also suggested that as a quick fix James Norman Health Information Resources could be contacted for extra signage but that she would also take this to Stephanie Broadbent to explore how signage could be more colourful and therefore more visible. KDW Mental Health MY spoke on the report informing the Committee that issues continue as per the last sector report. Progress Against Areas of Concern Previously Reported 2 a) High Waste Segregation There is still no conclusion to this. AC suggested that MY spoke to JWa regarding this as the situation seems to have improved within Woodend Hospital. MY will contact JWa to discuss MY 5

4 Standing Items cont.. 2 b) Low Hand Hygiene Training Compliance This data is now able to pulled from the AT Learning system and compliance with the mandatory training package has increased slightly There are still some issues with extracting Standard Infection Control Precautions (SICPs) elearning compliance data though. AC asked for information on audit training MY replied that a recent audit showed 100% compliance but when a back to the floor was completed issues were flagged up. PEH advised that this was why Quality Assurance audits were done but at present that programme is on hold until the new audit protocol has been assessed KDW added that it is imperative that Senior Charge Nurses be included in the Quality Assurance audit process with targets on improvement. This features on the HAI Education Group s sector report. So far lots of feedback has been received on the revised Hand Hygiene mandatory online elearning package. The protocol will be reviewed presently and from 1 st April auditing will be reintroduced. A discussion then commenced regarding the effectiveness of the Dress Code policy and its interpretation by members of staff. CMcQ stressed that support was needed for staff to help challenge those who do not adhere to the policy. AC agreed and added that a change of culture is needed also. HAI Education Group New Areas of Concern 1 c) Medium Mandatory Healthcare Waste elearning training package This is now out for final comment and the launch is imminent 1 d) High Ongoing issues with staff being able to attend / complete HAI Education sessions Other ways of delivery are being looked into including the possibility of offering lunchtime education as this seemed to work during Infection Control week. 1 e) Medium Incomplete implementation of PVC bundles/sticker across the organisation Donal Egan has now visited the majority of the areas with only Moray CHSCP to be completed 1 f) High Ongoing issues with staff not completing the Cleanliness Champions Programme within allocated timeframe The whole process is being reviewed. The course itself will be changing but this is still in discussion. Monthly cohorts are now being reintroduced to help staff manage their time and learning more efficiently. 6

4 Standing Items cont.. Areas of Achievement / Good Practice b) Staff are accessing the monthly themed HAI awareness courses but these are run by NHS Education for Scotland (NES) and are therefore completed via Learnpro and not AT Learning making it impossible to report on the number of staff completing the training, for NHS Grampian purposes. KDW is attempting to obtain the SCORM files so that these can be used to enable an Articulate package to be devised. c) Good progress is being made within the HAI Education Delivery Plan. The Group has been running for 18 months now and many changes have been made for the better. Attendance has been an issue recently and this may have to be looked at. Perhaps the Group can become more of a virtual one to ensure progress can be maintained CMcQ agreed with KDW on the issue of lunchtime education sessions being helpful but of course this cannot be mandated to staff. However as long as it is a voluntary option then this can be looked into and supported by management. Item 4.2 HAI Work Plan PEH spoke to the report informing the new members of the Committee that this report was formed from the HAI Taskforce Delivery Plan and aligned with the National Quality Strategy. Recommendations from the Vale Of Leven enquiry have been added to the report this year. We may have to look at another way of reporting aligning ourselves to the new SARHAI 5 year strategy. Updates have not been received for some actions and PEH will raise this with the Leads involved PEH then spoke to some of the actions Delivery Area 7 Surveillance 7.2 Ensure that HAI IT infrastructure is strengthened to allow for more flexible surveillance programmes This involves ICNet and is being progressed although there are still some issues that need to be resolved Vale of Leven recommendations 40 Health Boards should ensure that key principles of prudent antibiotic prescribing are adhered to PEH asked if FMc and GMaC could advise on progress for this. FMc and PEH will look at the recommendations together AC and PEH to work on refreshing the report for the next meeting March 2016 PEH PEH / FMc AC / PEH 5 New Business Item 5.1 HAI Report to the Board (HAI RT) PEH submitted the new look report to the Committee The Board had asked for a more meaningful report therefore it has been reworked. The front pages including the Key Matters relevant to recommendation section shown in a red, amber, green system are to help the Board to understand key issues surrounding Local Delivery Plan (LDP) targets. National figures have been used to ensure consistency and validation. 7

5 New Business cont.. Red flagged issues There are issue surrounding Clostridium difficile and although NHS Grampian are showing a better rate than the Scottish average we are unfortunately exceeding our LDP target for cases in the patients ages 15 and over; There are also issues surrounding clinicians documenting antibiotic prescribing and dosage with the LDP target being 95% FMc informed the Committee that NHS Grampian have been collecting data to analyse regarding this and it shows compliance. The Point Prevalence audit that is done yearly is a good indicator but some wards are poorer at documentation than others, although a recent study has shown improvements in these wards figures. Other Health Boards collate more data than NHS Grampian but where they concentrate on certain areas throughout, even if 100% compliant,our data collection is from a wider base. We move on to monitor other areas once the area is compliant. This could be reflected in the figures. In addition NHS Grampian compliance with prescribing protocol is higher than the Scottish average. Amber flagged Issues MRSA (CRA) Screening is also above the Scottish average but the LDP target shows compliance must be 90%. PEH advised that no health Boards are meeting this compliance figure. Surgical Site Infections are also shown as an amber issue but PEH stressed we should be cautious about making assumptions here. NHS Grampian are usually well under the Scottish average but 2 SSIs within Hip Athroplasty have been documented recently (see page 12) The rest of the report details Key Matters. The Scorecards have been left in the report but there has been a reduction in the number of graphs. Page 3 shows new information with regard to Staphylococcus aureus Bacteraemia (SABs) Surveillance and contains a pie chart showing the origin of the SAB case and a table documenting the source of infection. PEH asked the Committee if they felt that this new addition to the report was helpful? It could give more scope to reduce these SABs if the sources were identified. BP replied that new surveillance regarding SABs was beneficial and was being fed back to clinicians to keep them involved. Page 6 details Clostridium difficile infections and shows that there is an even split in figures between cases classified as Healthcare Associated and Out of Hospital. The graphs on page 7 are shown to provide assurance and show that NHS Grampian are below average in the 65 years and above category but in the 15-64 years category there is little movement. Page 10 contains a new table which details the Cleaning compliance within NHS Grampian and shows that we continue to achieve the required cleanliness standards across all locations. DW also informed the Committee of a recent Diphtheria incident which occurred. The patient had contracted the bacterial infection prior to being admitted and unfortunately died before a positive result was obtained. By this time there had been a high level of contact with healthcare staff who then had to be identified, tested and inoculated as deemed necessary. An Incident Management Team was established which met twice to investigate and manage the incident. 8

5 New Business cont.. Page 11 PEH asked FMc whether anything else should be included surrounding Antimicrobial Prescribing. FMc will liaise with PEH on this PEH / FMc The Committee were happy with the report Item 5.2 HAI Report to the Clinical Governance Committee PEH asked the Committee which points they would like to be included in the report to the Clinical Governance Committee. It was decided that the following issues should be included all Very High and High risks from the Sector Reports all Good Practice 6 AOCB Recurrent Clostridium difficile Infection (CDI) Treatment Guide This report was written and submitted to the Committee for approval from BP and AMK BP spoke on the report informing the Committee that he and AMK are attempting to tackle the issue of recurrence of Clostridium difficile infections and the benefits of prescribing Fidaxomicine. This paper will be going to the Antimicrobial Group for comment at the next meeting. Both BP & AMK felt that although Fidaxomicine is a more expensive drug initially the benefits would reduce costs in the long term and that patients with recurrent Clostridium difficile infections need to have the opportunity to be prescribed the drug. Both Infection Prevention and Control Doctors asked for the Infection Control Committee s support with this. Once discussed at the Antimicrobial Management Group the recommendations will then, hopefully, be distributed across NHS Grampian. Champions Challenged Conference KDW informed the Committee that this year s Conference will be taking place at the AECC on 21 June and that all members were invited to attend. 7 Date of Next Meeting 29 March 2016 11.00 13.00 The Conference Room, McGillivray Centre, Aberdeen Maternity Hospital 9