LOTHIAN HEALTH BOARD Edinburgh Community Health Partnership Sub Committee Meeting 16 th April 2009 Clinical Director (Dr Carl Bickler Clinical Lead SE LHP) CLINICAL REPORT 1 Purpose of the Report The purpose of this report is to update the Sub Committee of clinical developments within the CHP and to update it on clinical governance issues that either arise within the CHP area or, if they arise elsewhere, could be of interest to the CHP. It is also to update the CHP Sub Committee on clinical governance activity and the progress made in the Edinburgh CHP Quality Improvement Team and its Quality Improvement Programme. SUMMARY An update on recent critical incident findings. A report on Datix reporting in included. A report on HAI activity is included. A report on recent Handwashing audits is included. An update on the Keep Well extension plan. An update on the HMIe inspection. An update on GPs and hand hygiene. 2 Recommendations The Edinburgh CHP Committee is invited to:- 2.1 Note that the two critical incident investigations involving the loss of patient information have been fully investigated and recommendations have been agreed. 2.2 Note and discuss the enclosed Datix reporting activity. (appendix 1)
2.3 Note and discuss the enclosed HAI activity data. (appendix 2) 2.4 Note and discuss the enclosed Hand hygiene audit findings. (appendix 3) 2.5 Note the update on the Keep Well extension plan. 2.6 Note the recent discussions around GPs and hand hygiene. 3 Updates from previous Clinical Report 3.1 Critical Incident Missing Family in Need (FIN) Record 3.1.1 It was reported in the last clinical report (11/12/08) that a FIN record disappeared whilst in transit between 2 health service sites in Edinburgh and that a critical incident review group was established, a Root Cause Analysis (RCA) commissioned and a report with recommendations produced. 3.1.2 The recommendation to purchase secure envopaks and a handheld electronic tracking system for the safe transfer of all community health records has been agreed by the Quality Improvement Team Leadership Group (QITLG). 3.1.3 The ECHP General Manager will ask the members of the Finance and Performance Group to adopt these recommendations across the four CH(C)Ps and identify the means to fund the proposal. 3.1.4 The report along with the agreed recommendations will be taken to the Healthcare Governance and Risk Management Committee via the Director of Public Health in the near future. 3.2 Critical Incident Initial Referral Document (IRD) 3.2.1 It was reported in the last clinical report (11/12/08) that a child protection IRD was found in the Leith area of Edinburgh and that a critical incident review group was established, a Root Cause Analysis commissioned and a report with recommendations produced. 3.2.2 The recommendations will be taken to the next QITLG meeting for approval. 3.2.3 The report along with the agreed recommendations will be taken to the Healthcare Governance and Risk Management Committee via the Director of Public Health in the near future. 3.2.4 The report will also be taken through other groups within the CHP to enable a full discussion of the findings. 2
4. Datix Incident Reports 4.1 The enclosed report (appendix 1) is the first Datix incident report produced for the QIT. 4.2 The main incident categories reported; falls, violence and aggression, Medication incidents, sharps, medical devices / equipment and data protection have been agreed by the QITLG. 4.2.1 It should be noted that as this is the first report of this kind since the implementation of Datix in the CHP in November 2008, it is therefore not possible to set a benchmark for data comparison. 4.2.2 The levels reported have been reviewed by heads of service at the QIT meeting and are not considered unusually high and no remedial action has been recommended. 5. HAI 5.1 At the time of writing this report there are no abnormal reports in the incidence of recorded HAI rates in the CHP. 5.1.1 A copy of the HAI report for the quality improvement team is enclosed as an appendix. (appendix 2) 5.2 Non MRSA / C diff HAI Issues 5.2.1 During this reporting period there was an outbreak of a viral gastro enteritis type illness at Findlay House. No causative organism was isolated. 5.2.2 Two wards were closed during the outbreak and terminal cleans were carried out prior to reopening. 6. Hand Hygiene Audits 6.1 The enclosed hand hygiene audit report (appendix 3) reports on the findings of the hand hygiene audits carried out over a three month period in some of the patient areas in the CHP. 6.2 The audits were undertaken by the infection control nurse (ICN) using the NHS Lothian hand hygiene audit tool and a national audit tool. 6.3 The observations vary between the two audit tools used; the NHS Lothian tool measured a compliance rate of 23% - 70 % and the national tool measured 55% - 90% compliance. 6.4 The ICN plans to complete hand hygiene audits in all in-patient areas in the future. 3
6.5 Action plans will be developed in all audited areas to maintain and improve compliance. 6.6 Non compliance will be recorded on Datix 6.7 The audit results will be forwarded to the Clinical Effectiveness team for collation. 7. Extension and Expansion of Keep Well 7.1 The CHP have received a further 1m of funding to extend the Keep Well pilot until 2010. 7.1.1 The extension period will see a continuation of many of the activities undertaken during the first phase and will focus on engaging with those patients yet to accept or decline a health check as well as offering the service to patients (registered with participating practices) reaching 45 years during the extension. In addition, the extension will see: more targeted community based engagement work, including the roll out of doorstep engagement; the expansion of the health check to include high level anxiety and depression screening questions, a carers status question, and prompts regarding eligibility for bowel, cervical and breast screening. Work will also be undertaken to enhance and expand the outreach worker service in an effort to make it accessible by more adults living within deprived communities. 7.1.2 All practices who participated in the initial pilot have committed to continuing participation during the extension phase. 7.2 NHS Lothian has also received additional national funding to expand Keep Well activities to other geographical areas and population groups. As a result a number of different initiatives are planned and will commence during 09/10. 7.2.1 A Keep Well pilot will be established in West Lothian CHCP. It is anticipated the pilot will be developed in a way which incorporates lessons and knowledge from the Edinburgh pilot. 7.2.2 A small team will be established to work specifically with Gypsy/Traveller communities (across Lothian). It should be noted due to the very low average life expectancy among this population group the eligibility for Keep Well health check is to be lowered to 35 years. 7.2.3 An ethnic minority health team will be established to work with general practices to support enhanced engagement with ethnic minority patients in an effort to support enhanced health improvement interventions and management of long term conditions. 7.2.4 Scottish Prisons Service has received funding to provide Keep Well health checks for long term prisoners, NHS Lothian will seek to complement this by establishing a team focused on supporting prison leavers to address their health 4
and wellbeing needs and access associated mainstream services. It is anticipated funding will initially allow these initiatives to run for 2-3 years. 8. HMIe Child Protection Inspection 8.1 Background 8.1.1 In response to the Edinburgh HMIe Inspection report (Sept 07), The Edinburgh Child Protection Committee (ECPC) and Quality assurance Sub Group produced an action plan which was submitted to the Scottish Government in January 2008. 8.1.2 Simultaneously the City of Edinburgh Council and partners developed a performance management framework and balanced scorecard. This tool was developed further with all statutory partners in 2008. 8.1.3 A Follow-Through Interim Inspection took place in June 2008 and the final report was published in September 2008. The report highlighted some areas of insufficient improvement. 8.1.4 Since the report was published many of the issues have been addressed and a wide range of improvements reported. 8.2 Next Steps 8.2.1 A full inspection by HMIe to review Edinburgh progress in relation to the Framework for Standards for Quality Indicators will take place in June 2009. Preparation for this inspection is ongoing and is led by the ECPC Quality Assurance Sub Group. 8.2.2 HMIe have recently revised the Child Protection Inspection format and new guidance will be issued in April 2009. 8.2.3 Sally Lee, former Chief Nurse and newly appointed Child Health Commissioner will continue to lead on the health preparation for the inspection supported by Ailene Preston, Public Health Team Manager. 9. GPs and Hand Hygiene 9.1 In October 2008 a lay member of the Control of Infection Committee (CIC) raised concerns that recent observations during GP home visits showed a lack of hand washing before examining patients. 9.2 Dr McKay, Clinical Director subsequently raised this observation locally with the ECHP Clinical Leads and the GP Sub Committee. 9.3 The ECHP Clinical Leads have attempted to raise the profile of this issue at local GP rep meetings. 5
9.4 The GP Sub Committee have advised GPs to follow good practice when visiting patients at home. 9.5 The lack of evidence relating to this issue has been noted and it has been agreed to wait for Health Protection Scotland to issue guidance before commenting further. Author: Dr Carl Bickler Date: 2nd April 2009 6
LOTHIAN HEALTH BOARD Edinburgh CHP Quality Improvement Team 27 th February 2009 Dr Ian McKay Clinical Director 1 Purpose of the Report INCIDENT REPORTING 01/10/08 31/12/08 1.1 The purpose of this report is to update the Quality Improvement Team (QIT) on incident activity across the Edinburgh Community Health Partnership (ECHP) and decide if any action required. 2 Recommendations The QIT is invited to: 2.1 Note the current level of incident activity. 3 Background 3.1 DATIX is an intranet web based searchable database used to store medication incidents, critical incidents and complaints. 3.2 The QIT Administrator will produce a quarterly report on incident activity which will be analysed by the Clinical Director and Chief Nurse before being presented to the QIT. 4 Reporting Templates The 6 main incident categories; Falls, Violence and Aggression, Medication Incidents, Medical Devices / Equipment, Sharps and Data Protection have been agreed: 4.1.1 Falls Location Type of fall Number of patient falls Number of staff falls
4.1.2 Violence and Aggression Location Type of abuse Violence towards staff Violence towards patients Full analysis of reported incidents of sexual abuse 4.1.3 Medication Incidents The Associate Director of Pharmacy will lead on the analysis of medication incidents and report these to the QIT and QITLG. 4.1.4 Sharps Location Patient injuries Staff injuries Severity of injury Administration of anti retroviral prophylaxis 4.1.5 Medical Devices and Equipment A full analysis will be completed on each incident. 4.1.6 Data Protection A full analysis will be completed on each incident. 5 Incident Reports 5.1 Falls 5.1.1 The total number of falls reported was 239 5.1.2 The number of staff falls recorded was 15 5.1.3 The number of patient falls recorded was 224 5.1.4 The exact locations of the incidents were recorded as follows: 2
Location Number of incidents Astley Ainslie Hospital 124 Conan Doyle Centre 1 Corstorphine Hospital 7 Ellen's Glen House 4 Ferryfield House 19 Findlay House 31 Gracemount Medical Centre 3 Leith Community Treatment Centre 3 Liberton 12 McLeod Street 1 Muirhouse Medical Group 1 Royal Edinburgh Hospital 29 Sighthill Health Centre 1 Springwell House 2 Stockbridge Health Centre 1 Total 239 5.1.5 The type of falls was recoded as follows: 5.2 Violence and Aggression 5.2.1 The total number of V&A incidents recorded was 127 5.2.2 The number of incidents against staff was 90 5.2.3 The number of incidents against patients was 37 5.2.4 The exact locations of the incidents were recorded as follows: 3
Location Number of incidents Astley Ainslie Hospital 42 Corstorphine Hospital 2 Edinburgh Homeless Practice 1 Ellen's Glen House 7 Ferryfield House 4 Findlay House 5 Hermitage Medical Practices 1 Muirhouse Medical Group 1 Off-site other 2 Restalrig Park Medical Centre 1 Royal Edinburgh Hospital 55 Sighthill Health Centre 4 Stockbridge Health Centre 1 Whinpark Medical Centre 1 Total 127 5.2.5 The type of incident was recorded as follows: Type of Incident Total Other 7 Physical abuse 93 Sexual abuse 2 Verbal abuse 25 Total 127 5.2.6 The reported cases of sexual abuse are detailed below: Date of Incident Location Details Action Taken 21/10/2008 Ellens V&A Pt to staff while attending to Pt made Glen personal care. Staff asked pt if they aware that House needed help to get into bed, pt said their yes, as staff was carrying out duties behaviour pt grabbed staff's hair and verbally was abused staff. Staff managed to diffuse unacceptable the situation but pt followed staff as later they made to leave the room, again apologised. grabbed staff and attempted to kiss her. Staff reported incident to team leader. Pt continued to follow staff around for the rest of the night, staff had to lock other pt's doors when attending to their care to prevent V&A entering room. Result No known adverse effect at this time 07/11/08 Robert Ferguson Unit Ward 17 Nursing assistant was assisting patient in the shower. Patient grabbed shower head and was waving it about, when staff tried to retrieve the shower head, patient grabbed out at staff member's breasts. Staff told patient to stop. No known adverse effect at this time 4
5.3 Medication Incidents 5.3.1 Medication Incidents will be reported under separate cover by the Associate Director of Pharmacy. 5.4 Sharps 5.4.1 The total number of sharps incidents reported was 15 5.4.2 The number of reported injuries to staff was 10 5.4.3 The number of reported injuries to patients was 0 5.4.4 5 of the incidents did not cause injury to staff of patients. 5.4.5 The exact locations of the incidents were recorded as follows: 5.5 Medical Devices / Equipment 5.5.1 A total of 32 incidents were reported under the categories Medical Equipment / Hit by Equipment. 5.5.2 11 incidents related to syringe driver malfunction. 5.5.3 5 incidents related to accidents relating to beds / chairs / hoists. 5.5.4 4 incidents related to staff cars. 5.5.5 12 incidents were adhoc incidents and were recorded under other. 5
5.6 Data Protection 5.6.1 1 incident was reported under the category of data protection. 5.6.2 A photocopy of a set of patient s notes was found in the pocket of a laptop used by the Family Planning Service. The patient record had been put in the bag to be taken back to Dean Terrace after the patient has been seen at Howden Family Planning Clinic. The record was discovered 6 months after the appointment. The record was returned to Dean Terrace and filed with the rest of the patients notes. 6 Significant Adverse Events 6.1 Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) 6.1.1 October-December 2008-6 incidents were reported to the Health & Safety Executive under RIDDOR 6.2 Incident with a Severity = Death/Major Harm There were no incident reports with actual severity = death. 3 incidents were reported on Datix with actual severity = major, these incidents are highlighted in Table 1. Table 1 Incident Description Outcome Actions as recorded on DATIX 1). Employee fell over when walking from car park to school entrance, put arms out to save herself when she fell. Reported to HSE 2). Patient lost her balance and fell. Incident occurred in the bathroom within the ward. 3). Patient at home fell backwards after getting up from the edge of the bed and reaching into the wardrobe to get his wallet. The DN did not see what happened as she was writing up her notes at the time. Major Harm Attended WGH Minor Injuries - referred to RIE Fracture Clinic. Fracture to left hand Major Harm Major Harm Patient assisted with the full bodied hoist and taken back to the room and made comfortable in her bed. The cut was cleaned and the on-call doctor came in to see her. Fracture to left leg and laceration to face Patient made comfortable, DN called 999 requested an ambulance. GP visit also requested to give analgesia. The patient suffered a fractured left femur and was admitted to hospital. Investigation Status Open Open Open 6
7 Actions required 7.1 As levels are not considered to be unusually high and no immediate remedial action is required. 8 Resource Implications 8.1 There is no resource implications associated with this report. Jennifer Evans QI Administrator 19 th February 2008 7
LOTHIAN HEALTH BOARD Edinburgh CHP Quality Improvement Team 27 th February 2009 Dr Ian McKay Clinical Director HEALTHCARE ASSOCIATED INFECTION 1 Purpose of the Report 1.1 The purpose of this report is to update the Quality Improvement Team (QIT) on the current levels and trends of Healthcare Associated Infection (HAI) and any remedial action required as a result of deviations from normal background levels. 2 Recommendations The QIT is invited to: 2.1 Note the current levels and trends of HAI 3 Background 3.1 HAI is a major cause or morbidity and mortality for patients especially those on hospital sites. 3.2 It is generally accepted that HAI can be minimised and indeed eradicated if simple hygiene measures and prudent antimicrobial prescribing policies are adhered to. 3.3 In addition NHS Scotland has set a HEAT target (T5) to reduce MRSA bacteraemia by 30% by 2010. 3.4 The CHP routinely monitors background HAI levels in both its hospital and community sites. It works closely with the NHS Lothian infection control team to minimise the risk of HAI and to implement policies, procedures and guidelines. 3.5 NHS Scotland and NHS Lothian routinely monitor levels of MRSA bacteraemia and Clostridium difficile isolates. These levels are reported locally and nationally and can be benchmarked against other health board areas and internally between operating divisions and CHPs.
4 Edinburgh CHP HAI levels 4.1 MRSA Bacteraemia 4.1.1 NHS Lothian MRSA rates NHS Lothian MRSA Rates Jan 08 - Jan 08 60.0% 57.0% 50.0% 40.0% 30.0% 29.0% 20.0% 10.0% 2.0% 4.0% 1.0% 1.3% 3.3% 2.4% 0.0% 1 2 3 4 5 6 7 8 1. CHP Managed Site 5. Roodlands 2. Liberton 6. RVH 3. RHSC 7. SJH 4. RIE 8. WGH 4.1.2 MRSA Bacteraemia trends comparing RIE and Edinburgh CHP 12 RIE / Edinburgh CHP MRSA Episodes Jan 08 - Jan 09 10 8 6 4 2 0 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 ECHP 2 RIE
4.1.3 Edinburgh CHP MRSA Bacteraemias MRSA Episodes CHP Managed Sites Jan 08 - Jan 09 2 1.5 1 0.5 0 AAH - Mears Ward AAH - East Pavilion B 4.2 Clostridium difficile (c diff) 4.2.1 NHS Lothian C. diff rates NHS Lothian C diff Episodes Jan 08 - Jan 09 No. of Cases 450 400 350 300 250 200 150 100 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1 EDINBURGH CHP MANAGED SITES 11 TIPPETHILL HOSPITAL 2 EDINBURGH CHP GENERAL PRACTICES 12 - WGH 3 - EAST LOTHIAN GENERAL PRACTICES 13 - HERMANDFLAT 4 MID LOTHIAN GENERAL PRACTICES 14 - LIBERTON 5 WEST LOTHIAN GENERAL PRACTICES 15 LOANHEAD HOSPITAL 6 RIE 16 LOCATION NOT GIVEN 7 ROODLANDS 17 - REH 8 RVH 18 - RHSC 9 St JOHNS 19 - EDENHALL 10 - HOSPICES 3
4.2.2 RIE and ECHP C. diff Rates RIE / Edinburgh CHP (inc GP Practices) C diff Episodes Jan 08 - Jan 09 50 45 40 35 30 25 20 15 10 5 0 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 ECHP RIE 4.2.3 C.diff episodes in ECHP Managed Sites Cdiff Episodes CHP Managed Hospital Site Jan 08 - Jan 09 40 35 30 25 20 15 10 5 0 38 5 0 0 2 AAH Sites Ellens Glen House Findlay House Ferryfield House Liberton - Lanfine 4
4.2.4 C diff Episodes across Edinburgh and Mid, East and West Lothian managed sites. C diff Episodes CH(C)P Managed Sites Jan 08 - Jan 09 45 40 35 30 25 20 15 10 5 0 EL CHP Managed Site ECHP Managed Sites Mid Lothian Managed Sites West Lothian Managed Sites 4.2.5 C. diff Episodes recorded in ECHP General Practices C diff Episodes ECHP Jan 08 - Jan 09 30 25 20 15 10 5 0 North East 21 26 21 19 North West South Central South East 11 South West 5
4.2.6 C. diff trends across ECHP General Practices 14 12 10 C diff Episodes LHP General Practice Jan 08 - Jan 09 8 6 4 Series1 Series2 Series3 2 0 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Series4 Series5 Series6 5 Non MRSA / C.diff HAI issues 5.1 There has been an outbreak of a viral gastro enteritis type illness at Findlay House. No causative organism has been isolated. 5.2 Both Prospect Band and Fillyside wards have been affected. 5.3 Fillyside had 4 cases and closed on 01/01/09 and reopened 05/01/09. 5.4 Prospect Bank had 12 cases and closed on 02/01/09 and reopened on 12/01/09. 5.5 Terminal cleans were carried out in both wards prior to reopening. 6 Actions required 6.1 Immediate action was taken to prevent the spread of infection in Findlay House with the wards closed to new admissions and cleaned as above. 6.2 It should be noted that this happened at a time when there was increasing pressure on acute hospital beds. 6.3 Closure to admissions, cleaning and reopening followed best practice and control of infection was of paramount importance. 6
7 Resource Implications 7.1 There is no resource implications associated with this report. Jennifer Evans QI Administrator 24 th February 2009 7
LOTHIAN HEALTH BOARD Edinburgh CHP Performance Management Sub Group 18 th March 2009 Audrey Pringle Infection Control Nurse HAND HYGIENE AUDITS 1 Purpose of the Report 1.1 The purpose of this report is to update the Performance Management Sub Group (PMSG) on the current position within Astley Ainslie Hospital 1.2 The paper will also discuss the NHS Lothian HAI Audit Tool and the NHS Scotland Hand Hygiene Audit Tool, from which the Hand Hygiene Audit is results are compiled. 2 Recommendations The PMSG is invited to: 2.1.1 Note the current position with regards to hand Hygiene and consider how best to facilitate the rolling out of the HAI Audit Tool. 2.1.2 The group are also invited to consider how hand hygiene compliance within the community setting could be monitored. 3 Background 3.1 Over the past three months, Hand Hygiene audits have been undertaken within some of the in-patient areas. More audits are planned for the forthcoming moths. 3.2 Audits have been undertaken by Audrey Pringle using the NHS Lothian Hand Hygiene Audit Tool. Audits have also been undertaken by Ann McQueen, Hand Hygiene Co-ordinator for NHS Lothian, using the National Audit Tool. 3.3 These audits produce different results, as they measure compliance differently. It is generally felt that the NHS Lothian Tool is far more detailed and more robust
that the National Tool. The NHS Lothian Hand Hygiene Audit Tool is the preferred tool for auditing Hand Hygiene across NHS Lothian. 3.4 The main differences between the tools are: 3.4.2 The National Tool has 20 observations and the Lothian Tool has 30 observations. 3.4.3 The National Tool is a once only snap shot. The Lothian Tool is planned to be undertaken on a monthly basis, by clinical staff and the observations carried out over the month. 3.4.4 The National Tool scores on Opportunities Taken only. The Lothian Tool scores on Opportunities Taken, Technique and Bare Below the Elbows. 4 Edinburgh CHP HAND HYGIENE AUDITS 4.1 National Tool 4.1.1 Results (in percentage) from wards on AAH site audited using National Hand Hygiene Campaign Audit Tool. 100% 80% 60% 40% 20% 0% Mears MBA MBB EPA EPB McCallum CB1 CB2 Sutherland Miles 2
4.2 NHS Lothian HAI Audit Tool 4.2.1 Results (in percentage) from wards on AAH site audited using NHS Lothian HAI Audit Tool. 80% 60% 40% 20% 0% Mears MBA MBB McCallum CB2 Sutherland Miles Actions required 6.1 Completion of audits by ICN, to provide baseline audits for all in-patient areas. 6.2 Introduction of HAI Audit Tool across Edinburgh CHP in-patient areas. 6.3 Updated tool to be issued 1 st April 2009, to comply with Scottish Governments Zero Tolerance position with regard to hand hygiene. This will include the removal of the amber status and increase the compliance to 95%, across all disciplines. 6.4 Action plans to be developed by audited areas. Infection Control Nurses are available to offer support with any educational or training issues that may be identified. 6.5 Non-compliance will be recorded on Datix. 6.6 Results will be forwarded to Clinical Effectiveness for collation, ICN and Line Manager. Resource Implications 7.1.1 The resource implications for the introduction of this tool would be considered to be mostly concerned with time management issues, as data collection and input will be required to be undertaken. 3
7.1.2 Additional PC access may be required. Audrey Pringle Infection Control Nurse 17 th March 2009 4