NHS GRAMPIAN Infection Control Committee Minutes from meeting held on 10 July 2014 The Conference Room, Aberdeen Maternity Hospital 11.00 13.00 Present: Pamela Harrison, Infection Prevention & Control Manager (Chair) MY Mandy Young, Operational Support Nurse Manager Mental Health (deputising for Jenny Gibb) RAB Roy Browning, Senior Infection Prevention & Control Nurse LM Leonora Montgomery, Public Forum Representative FM Fiona Mitchelhill, Safe Team Leader - Quality Governance and Risk Unit KT Keith Thomson, Head of Health & Safety NHSG AMK Anne Marie Karcher, Infection Prevention & Control Doctor EO Emmanuel Okpo, Consultant in Public Health Medicine (VC) AMC Alison McGruther, Unit Nurse Manager, Elderly and Rehabilitation Services VM Val MacDonald, Decontamination Services Manager (deputising for Juliette Watson) GMac Gillian Macartney, Antibiotic Pharmacist SS Sue Swift, Head of Nursing, Women and Children s Division, Combined Child Health KDW Karen Wares, Nurse Consultant - HAI 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 : Elinor Smith (ES) Gary Mortimer (GM) Pamela Molyneaux (PM) Gladys Buchan (GB) Jane Adam (JA) Sandy Thomson (ST) Audrey Bell (AB) Alison Hardy (AH) 2 Minutes of last meeting 24 March 2014 The minutes from 2 June 2014 were ratified by the Committee with no amendments. AS 3 Matters Arising Item 3.1 Equipment Cleaning Implementation Group Update There have been issues with recruitment of a manager for the Bed Busting Team but this has now been resolved and the position has been filled; member of staff is due to commence at the end of August 2014. With regards to the A- Z an email was sent Grampian wide approximately 3 weeks ago which contained the A-Z document, HPS flowchart and the new monitoring sheet for equipment cleaning. Feedback from this shows confusion amongst staff and will, therefore, be explained in more detail at the local HAI Group meeting. 1
3 Matters Arising cont. The annual MOT Service of equipment is still work in progress and a programme of service and maintenance is needed. In addition the Maintenance Team are concerned with regard to grossly contaminated equipment being cleaned as per manufacturer s guidelines where these are present. KT replied that one of the issues with cleaning beds could be resolved by simply replacing the end caps although Alistair Gilchrist has not raised this at the Equipment Cleaning Implementation Group meetings. There is also confusion in the Community as to whose responsibility it is to clean beds. The MOT document needs to be all encompassing. The topic of training with regard to the cleaning of patient equipment is no longer discussed at the Thursday meeting but gave an update. Clinell training was delivered at Aberdeen Maternity Hospital and Ward 8, Aberdeen Royal Infirmary in June and was well received and with good feedback being given. Clinell are being approached to discuss a Grampian wide rollout of this training. Item 3.2 NHS Grampian HAI Education Framework KDW informed the Committee that this protocol replaces the expired document that was originally formulated by Jane Ormerod; it has been circulated to the Education Group. KDW also stated that the Group require more representation from across NHS Grampian. The Education Group meet again on 5 August 2014 and during this time the Framework document may incur changes due to a hold up with the national mandatory training requirements. KDW will update the Committee in due course when the National Guidelines are received. stressed that NHS Grampian should not try to duplicate training already delivered by NHS Education for Scotland. Any training undertaken by staff via NHS Education for Scotland (NES) is not recorded on our training system (AT Learning) and therefore not recorded on staff s Personal Development Plans (PDPs). FM informed the Committee that Health Protection Scotland (HPS) and Information Services Division Scotland (ISD) have now merged and are known as Public Health Intelligence (PHI) although there has been no formal update received, on this, as yet. GMac requested that the term mandatory be defined within the framework document and this training perhaps be listed for more staff awareness. KDW replied that this was included in the document at one time but the Group decided it should be removed. suggested that perhaps the Grampian Area Partnership Forum (GAPF) may have the mandatory aspect of training covered already? KDW to add a paragraph under the heading Local Mandatory HAI Training on pages 11/12 to cover this issue. stated that a delivery plan for the framework will be devised and shared with the Committee in due course. Subject to minor changes the Infection Control Committee ratified the document. KDW 2
4 Standing Items Item 4.1 Sector Reports Acute stated to the members that she feels there in some overlap with certain areas of the Sector Reports. New areas of concern 1 a) High Flushing of water outlets for Pseudomonas in high risk areas. SS raised the fact that compliance was variable across the Acute Sector. AH has suggested that spot check audits should perhaps take place as education is needed surrounding this topic. AMH Requirement for a Theatre specific audit tool. This tool is being reviewed AH and to discuss. SS asked to be included in discussions surrounding this issue. AH / 1 b) Medium AMH HEI Group There is to be a change in the structure of this Group and its meetings to ensure more focus on feedback from the HEI Inspectors and the completion of the required action plans 2 a) Medium Patient Placement Tool Utilisation This has been variable across Dr Gray s Hospital but has since much improved with work ongoing in Wards 3 and 7. Areas of Achievement / Good Practice 3 a) Hand Hygiene compliance across Dr Gray s Hospital is good 3 b) The reconfiguration work being carried out within Dr Gray s hospital is now completed Aberdeenshire CHP From the Aberdeenshire report, highlighted that HAI work and the Patient Safety Group are well linked but information is patchy across the Community sector. Allied Health Professionals working in some Community settings/hospitals have not been prioritised and the Infection Prevention and Control Team must refocus work on this group of staff. AMC suggested that perhaps AHP representation should be included on the Infection Control Committee to which replied that, historically, the Infection Control Committee is predominantly attended by high level management and leads from major services. will discuss with RSD / RSD 3
3 Standing Items cont SS also feedback that Anne Brockman Lead for Acute AHPs has identified, during audits, that the level of understanding surrounding infection control is inadequate in some areas. will take this to the various HAI Groups to discuss the AHP input into all areas. Aberdeen City CHP 2 a) High Issues flagged during the HEI Inspection relating to the Links Unit and Woodend Hospital included Decontamination sinks in the wrong rooms Insufficient sinks per patients Incorrect taps on some sinks This has been noted on the Woodend risk register. This is an NHS Grampian wide issue therefore audits to be piloted at Woodend should assist with information on the extent of work required across NHS Grampian. 1 b) High Incorrect Use of Patient Placement Tool Ongoing education sessions are being carried out with the help of the Woodend Infection Prevention & Control Nurse. 1 c) Very High Clinical Waste This is an ongoing issue that has been escalated to Facilities Management Team. The Waste Management Group (formerly Healthcare Waste Committee) has now been reconvened and will hopefully address the issue. KDW replied that mandatory Healthcare Waste training should help with waste segregation issues. Douglas Andrew is heading this. AMK insisted that interacting with staff at the point of incorrect waste segregation is key and SS added that perhaps the bin stickers contained too much information. confirmed that work is ongoing surrounding this issue and she will liaise with GM with regard to formulating a plan to move ahead with. Areas of Achievement / Good Practice 3 a) All wards are now compliant with Hand Hygiene audits 4
4 Standing Items cont Mental Health 2 c) Medium Waste Segregation MY fed back to the Committee that they are experiencing the same issues with waste segregation which is being challenged during management walk rounds but the cleanliness of the yellow Euro bins recently installed is still a problem. 1 b) Medium Dress Code Policy The issue of dress code non compliance is now moving forward quickly with Nursing staff and Allied Health Professionals (AHPs); Community staff will also be receiving new uniforms in due course. Facilities 2 a) Medium Sinks and taps compliance This is ongoing although there has been an audit tool devised which has now been taken forward within Inverurie and Woodend Hospitals. 2 b) High Equipment and Environmental Cleaning This is being addressed by the Equipment Group and through the environmental audits programme. Senior Charge Nurses and the Infection Prevention & Control Team are now using the same level of scrutiny with regards to the audit process and the focus is on improvement. 2 c) High Water Safety It seems that some areas are now flushing every day even though the area is not high risk. This needs to be addressed. Moray CHP No report was submitted for this sector to discuss with RSD on level of reporting Combined Child Health SS reported that work on electrical issues should have commenced on the week of 1 st July 2014 but were delayed due to the number of babies in the Intensive Therapy Unit. Air conditioning issues also need to be addressed. Hand Hygiene non compliance within Theatres has also been raised through the auditing process. The data will be entered into LanQuip as soon as possible and a Problem Assessment Group meeting will be held. 5
4 Standing Items cont. Item 4.2 HAI Work Plan 2014/15 (for information) updated the Committee, notifying them that this document is a work in progress and subsequently there are now fewer gaps in the reporting template Item 4.3 Risk Register (for discussion) ID 1557 - Instructions for cleaning patient equipment Very High asked the Committee if their opinion was that this risk level could be reduced. Work has been complete and the outcomes show improvement during the weekly checks. Improvement s in cleanliness have been seen although this requires to be an ongoing piece of work for sustainability. Extra guidelines are in place, the A Z and flowchart are now available and more robust processes have been embedded. AMK questioned whether the results obtained by the internal Management Teams were significantly better than before and suggested that past and present audits should be looked at together. replied that Back To the Floor audits have been replaced with a new environmental audit process and suggested that the way forward would be to engage with the Manager and offer assistance to ensure that standard of auditing remains consistent. Results will require ongoing monitoring. MY expressed concern that areas are using environmental audits as a tick box exercise and reiterated the need for directorate level walkrounds. The Committee agreed. SS was also concerned that overloading staff with audit exercises could be detrimental if staff felt they were not trusted to comply with infection control policies / procedures in their day to day duties. No decision was agreed upon as to whether the risk could be reduced. will liaise with Andrew Wood surrounding the issue of risk ownership. ID 1592 Policies and Procedures The procedure for Waste Management and Segregation of Waste is inconsistently applied across NHS Grampian; needs to be put back in place and adhered to by staff. asked the Committee whether they felt a new risk should be opened surrounding the Waste Management Group (formerly the Healthcare Waste Committee)? The decision was made to open a new risk. will add narrative to controls and action columns. Item 4.4 Health Protection Scotland Exception Reports (non since last meeting) No reports to discuss 6
5 Reporting to Clinical Governance Committee & Board cont Item 5.1 HAI Report to the Board (aka HAIRT) explained that not all the data were yet available to be reported on. As soon as this data is received will update the report and email it out to all members. Item 5.2 HAI Report to the Clinical Governance Committee The Sector reports will be amalgamated and their information will be included in the report to the Committee. Also included in the report will be the issues with waste management and segregation and sinks. KT feedback that local committees have achieved good practice and asked for this also to be mentioned.. 6 AOCB Item 6 AOCB proposed that the HAI-RT be submitted for information only at future meetings. This was agreed. 7 Date of next meeting 11 November 2014 11.30 13.30, The Conference Room, MacGillivray Centre, Aberdeen Maternity Hospital 7