NHS GRAMPIAN

NHS GRAMPIAN
Infection Control Committee
Minutes from meeting held on 24 March 2014
The Conference Room, Aberdeen Maternity Hospital
10.30 – 12.30
Present:
RSD – Roelf Dijkhuizen, Medical Director NHSG (Chair)
PEH – Pamela Harrison, Infection Prevention and Control Manager
MY – Mandy Young, Operational Support Nurse Manager – Mental Health (deputising for Jenny Gibb)
LM – Leonora Montgomery, Public Forum Representative
RAB – Roy Browning, Senior Infection Prevention & Control Nurse
JA - Jane Adam, Public Forum Representative
FM – Fiona Mitchelhill, Safe Team Leader - Quality Governance and Risk Unit
GM – Gary Mortimer, General Manager, Facilities & Estates
NH – Neil Hendry, Practice Education Facilitator (deputising for Gladys Buchan)
AMK – Anne Marie Karcher, Infection Prevention & Control Doctor
EO – Emmanuel Okpo, Consultant in Public Health Medicine
EM – Eleanor Murray, Divisional Lead Nurse, Acute Sector
AMC – Alison McGruther, Unit Nurse Manager, Elderly and Rehabilitation Services (deputising for Frances Dunne)
AS - Anneke Street, PA to Infection Control Manager (Minute taker)
Item
1
Subject
Introduction and
Apologies
Action to be taken and Key Points raised in discussion
Action
Apologies were received from :
Elinor Smith (ES) Karen Wares (KDW) Juliette Watson (JW) Gillian Macartney (GMac)
Sandy Thomson (ST) Gladys Buchan (GB) Sandy Dustan (SD) Keith Thomson (KT) Jenny Gibb (JG)
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3
Minutes of last meeting
28 January 2014
The minutes from 28 January 2014 were ratified by the Committee with no amendments.
AS
Matters Arising
Item 3.1
Equipment Cleaning Implementation Group Update
GM updated the Committee and feedback that funding has been received for the recruitment of staff to the “bed
busting” pilot which will commence in the Emergency care Centre and Aberdeen Maternity Hospital presently.
Closing date for applications is 26 March 2014. It is hoped that the pilots will have commenced within 4 - 6
weeks of this date.
PEH updated members on the A-Z and the work still ongoing surrounding manufacturers guidelines and the use
of Actichlor Plus.
RSD requested, at this point, an update on the HEI unannounced visit to Aberdeen Maternity Hospital.
PEH replied that the Inspectors visited the same wards as previously, including Theatres, and found some
issues remaining with equipment cleaning; although the initial feedback seemed encouraging.
1
tem
3
Subject
Matters Arising cont….
Action to be taken and Key Points raised in discussion
Action
On receiving the written feedback, however, this was less positive than first thought although bed cleaning was
deemed to be adequate.
EM queried whether this related to the bed space checklist or the actual decontamination of the beds and PEH
replied that one area was found not to be using the required checklist. They are implementing a revised version
at present and this is being taken forward by the Obstetrics, Gynaecology and Neonatology HAI Group.
GM confirmed that an evaluation on the “bed busting” pilot would be available at the end of May or early June
and PEH stressed that it was important that the feedback required should contain views from staff, patients and
visitors to the hospital to ensure the feedback received is relevant.
4
Standing Items
Item 4.1
Sector Reports
Acute
New areas of concern
1 a) High – Flushing of water outlets for Pseudomonas in high risk areas is variable across the Acute Sector
EM and Diane Pacitti visited some areas regarding this. There is still work required and spot check to be carried
out.
1 b) Medium – 3 monthly environmental audit results still not being received from some areas. EM stated that
she would be in a better position at the next meeting to update.
Progress Against Areas of Concern Previously Reported
2 a) Very High – The cleaning of reusable equipment and the A to Z being produced nationally remains a very
high risk to NHS Grampian.
2 b) High – Some environmental audits and walk rounds are not being carried out on a regular basis. Divisional
Management teams need to focus on this more.
RSD informed the Committee that the Inspectorate were hugely supportive of the “Back to the Floor” sessions
that were taking place on a weekly basis. It is important that sessions are conducted in a supportive manner but
must also be challenging and meaningful to the area concerned.
EM replied that consistency surrounding audits must be achieved and suggested that non compliance with
protocol could be feedback via the Divisional General Managers / Lead Nurses meetings.
RSD suggested EM choose a forum to feed back to and liaise with the Infection Prevention and Control Team
with regard to expressing concerns on particular issues. Portfolios are important in ensuring staff are kept “in the
loop” and continue to feel involved. The subject of “areas not owned” should also be discussed with regard to
audits being submitted.
2
Item
3
Subject
Standing Items cont…
Action to be taken and Key Points raised in discussion
Action
2 c) High – There are still some issues with waste segregation and Divisional Teams have been encouraged to
carry out spot checks to ensure adherence to the policy. This is still a matter of concern.
RSD asked that EM take the opportunity to meet with the Divisional Teams and discuss ongoing and important
issues such as this with them.
EM and RSD agreed that understaffing is an issue in some areas and therefore impacts on compliance.
The matter of recruitment was raised at this point, with some members of the Committee feeling that the process
is long winded and can be complicated. The issue appears to be the funded establishment.
There are various Short Life Working Groups discussing this at present in the hope of providing a solution.
Areas of Achievement / Good Practice
3) There has been considerable progress made, so far, across the Acute sector with the environment looking
much improved with continued support from Facilities. More work is planned presently but momentum must be
kept to ensure sustainability.
Aberdeenshire CHP
Report was not submitted prior to the meeting but was distributed after.
NH gave a brief overview of some concerns stating that non compliant Hand Hygiene audits have been
occurring in various hospitals. Problem Assessment Group meetings have been held with the relevant staff
present.
The last round of quarterly HAI audits were, unfortunately, not as pleasing as the previous quarter’s. Short
staffing is seen as a contributing factor in this.
RSD enquired as to whether attitude and/or education could also be attributed to the results and stressed that
the correct people need to be present at any feed back meetings held.
PEH confirmed that the focus at the meetings she has attended has been on education but that attitude to this
piece of work is paramount also.
NH also informed the Committee that a full set of Quality Assurance visits has also been completed within the
Shire. Janice Rollo, GB and the Infection Prevention and Control Team have been active in completing these.
Aberdeen City CHP
New areas of concern
1 a) High – AMC spoke on the consistently low scoring during Standard Infection Control Precautions on the
cleaning of equipment and also waste segregation. This is being addressed by Management at ward level
through the use of the Standard Operating Procedures (SOP).
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Item
4
Subject
Standing Items cont…
Action to be taken and Key Points raised in discussion
Action
Management is also working with the Infection Prevention and Control Team to address waste segregation and it
is felt that a training package is required for staff to complete.
KDW, Ruth Cormack, KT and Douglas Andrew will meet to discuss this further
KDW
Progress Against Areas of Concern Previously Reported
2 a) High – Suspected HEI visit to Woodend and City Links Unit. NHS Grampian are awaiting the final feedback
report from the Inspectorate on the Woodend Hospital visit. Initial feedback at the time was positive with minor
considerations.
AMC voiced concerns that prior to the HEI visit, Management Teams were “back to floor” more often and this
level of scrutiny may now not be sustainable.
RSD replied that perhaps Management Teams should reconsider their priorities and responsibilities. Perhaps
more “back to the floor” time is a positive step forward for NHS Grampian.
Areas of Achievement / Good Practice
These included a plan to produce a quarterly report for all clinical areas (compiled through the quarterly reporting
system) to allow the Management Team to address, quickly, areas of concern within the hospital.
Weekly “Back to the Floor” sessions undertaken by the Infection Prevention and Control Team are progressing
well and are considered helpful to both staff and management.
Audits of equipment such as commodes and wheelchairs are ongoing.
Mental Health
New areas of concern
1 a) Medium – Non compliant waste bins require to be replaced across the service. A risk assessment has been
completed and MY and Shirley Porter have met with Stephanie Broadbent to agree a plan of action on this.
1 b) Medium – Mental Health and Learning Disabilities services to review the Healthcare Environmental Audit
Tool and Dress Code. Two short life working groups have been set up and have met to discuss these topics.
These groups will feedback results and progress through the Mental Health Infection Prevention and Control
Group.
1 c) Medium – Waste segregation. Yellow Euro bins are being installed, initially within Adult Mental Health
Directorate, within the next two weeks.
1 d) Medium – Risk Assessments require to be updated. These are in the process of being reviewed by the
relevant people.
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Item
4
Subject
Standing Items cont….
Action to be taken and Key Points raised in discussion
Action
1 e) Medium – Domestic washing machines in use within ward areas. MY is to complete a scoping exercise to
identify how many domestic machines are in use across the service. Once completed there will be further
discussion and agreement on how to proceed with this.
1 f) Low – Standard Operating Procedure for the decontamination of reusable equipment - A re-audit has taken
place using this procedure and a significant improvement has been shown in all areas. In areas of non
compliance, action plans have been formulated.
1 g) Low - Environmental audits. Annual audits have been scheduled throughout the year and a memo has
been circulated to all Senior Charge Nurses and team Leaders to ensure compliance in completing their 6monthly audits.
Progress Against Areas of Concern Previously Reported
2 a) Low – Inconsistency in execution of Hand Hygiene Audits. MY fed back to the Committee that sessions
have been held to train staff as “cascade trainers”; these staff are then expected to educate and guide ward staff
through Hand Hygiene training sessions. There still remains some confusion over the execution of audits and
therefore is has been requested that the Infection Prevention and Control Nurse for Mental Health attends a
meeting to discuss and advise staff on this process.
2 b) Medium - There have been a large number of non compliant Hand Hygiene audits across the service
resulting in numerous Problem Assessment Group (PAG) meetings. Compliance with Hand Hygiene is an issue
and Julie Fletcher is keen to ensure staff are aware of their obligations surrounding this. Action plans have been
completed and reviewed by the Senior Charge Nurse for each department/ward. Re-audits have taken place
within the agreed timescales and a report has been compiled highlighting common themes identified at PAG
meetings; this report has been discussed across the service and so that action can be taken to improve
compliance.
Areas of Achievement / Good Practice
These include the report that has been completed, highlighting common themes identified during PAG meetings
in relation to non compliant Hand Hygiene across the service.
Non alcohol gel has been sourced and installed for use in Dunnottar Ward (brain injury), Adult Mental Health and
the Mearns Suite.
Senior Charge Nurse Forum held in December 2013 which focussed solely on the subject of Infection
Prevention & Control. This session was well received by all who attended.
Facilities
New areas of concern
1 a) Medium – Sinks and taps compliance. Recent HEI inspections have highlighted the need for risk
assessments and future plans for dealing with sinks and taps that are non compliant with current guidelines.
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Item
4
Subject
Standing Items cont….
Action to be taken and Key Points raised in discussion
Action
A risk assessment is being developed and commenced in conjunction with the Estates Department and Infection
Prevention and Control Team with regard to swan neck taps, plugs and overflows.
Progress Against Areas of Concern Previously Reported
2 a) Medium – A need has been highlighted by the HEI Inspectors for the need to have independent calibrated
temperature monitoring of wash temperatures and times within domestic type washing machines. The
Committee were requested to give guidance on infection risks on this subject and whether risk is tolerable or
whether alternative options need to be considered. If the risk is deemed as high these machines will require to
be replaced.
2 b) High – HEI inspections have also identified gaps in equipment (nursing services) and environmental
(domestic services) cleaning. The “Bed Busting” SBAR submitted to the Committee at the November 2013
meeting has been supported and is now in the recruitment stage. A local A to Z of cleaning will be rolled out
across NHS Grampian and training and awareness for all staff is also nearing implementation.
2 c) High – A Risk Control Notice (RCN) has been issued to targeted high risk areas in response to
CEL(08)2013 Pseudomonas risks. Monitoring of compliance with this CEL will be via existing ward audits /
inspections, by managers, over the next 3 month period. Any inconsistencies to be discussed locally and
escalated as required. Risk Governance have requested a report due to DATIX results being inconclusive
2 d) High – Incidents of non compliance with the Waste Policy and waste segregation / storage / security had
increased, DATIX processes were not always followed as nursing / clinical staff are not always aware of the non
compliance. A global email has been issued with regard to Personal Protective Equipment (PPE) disposal in
clinical waste stream, a waste audit is to be completed across NHS Grampian by a specialist contractor and
waste disposal training is to be progressed with the help of the Infection Prevention & Control Team.
KDW / KT /
Douglas
Andrew
PEH and GM are now meeting regularly to deal with any issues and will be discussing the Pseudomonas topic.
PEH / GM
Dr Gray’s Hospital
Report was submitted but no one was available to speak on its contents
Moray CHSCP
Report was submitted late to the Committee but no one was available to speak on its contents
RSD suggested that Dr Gray’s Acute and Moray CHSCP sector reports be combined and submitted to the
Committee jointly. Hazel Whyte and Sean Coady to discuss and devise a joint statement.
Item 4.2
SC / HW
HAI Work Plan 2013/14 (for information)
This report was submitted for information only
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Item
4
Subject
Standing Items cont….
Item 4.3
Action to be taken and Key Points raised in discussion
Action
Risk Control Plan (for discussion)
PEH spoke on the report and concentrated on the Very High and High risks. This is now a DATIX report and is
reviewed monthly.
Instructions for cleaning patient equipment – Very High
Work on this is still in progress with regard to the NHSG A-Z for Decontamination of Re-usable Communal
Patient Equipment. This document is being monitored by the Equipment Cleaning Group.
HAI Education – High
Since Jonathan Lofthouse’s departure from NHS Grampian Amanda Croft has become the owner of this risk.
CJD Risk Assessment
There has been a marked improvement in processes surrounding this risk and the usage of the alert system.
PEH asked the Committee whether the level of risk could now be reduced ? It was agreed that it could be
lowered to Medium.
PEH
RSD stated that now the report was being reviewed on a monthly basis the Committee would only become
involved in decisions that required a reduction in risk.
A brief discussion followed surrounding DATIX reporting and it was agreed that work is required to ensure the
system is fit for purpose. RSD suggested this be discussed at the Patient Safety Lead Group.
Item 4.4
5
Reporting to Clinical
Governance Committee &
Board
Item 5.1
Health Protection Scotland Exception Reports (non since last meeting)
No reports to discuss
HAI Report to the Board (aka HAIRT)
This report was submitted to the Committee.
PEH stated that the quarterly national surveillance reports are not yet available.
Norovirus statistics for NHS Grampian have been low so far this year with only 2 wards closed across NHS
Grampian during January and February; this affected 13 patients. A marked reduction from this time last year.
RAB advised that this could be due to the exercise conducted to pre-empt the season and that, in addition to
this, environmental cleaning has been extended in areas that have been affected.
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Item
5
Subject
Reporting to Clinical
Governance Committee &
Board cont…
Item 5.2
Action to be taken and Key Points raised in discussion
Action
HAI Report to the Clinical Governance Committee
RSD asked the Committee if they felt anything from the Sector reports should be escalated ?
It was decided that a cross section would submitted to the Clinical Governance Committee including…
1) There are still variations in Divisional Management Teams’ approaches that must be addressed
2) Staffing levels could be contributing to non-compliance therefore Management walk rounds need to be
supportive and not punitive
3) Good practice from the Aberdeen City CHP Sector report should be recognised
RSD requested that this report be sent to the Committee, for information, at the next meeting in May.
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PEH
AOCB
Item 6.1
Infection Prevention and Control Back to the Floor Initiative
This report was submitted to the Committee
PEH spoke to the report informing members that it had been compiled and forwarded to General Managers in
January 2014. It contains a summary of works conducted across the whole of NHS Grampian.
Areas are prioritised for input by data collated from environmental audits and the intention is to be able to visit
every ward area within the current year. Visits began with concentration on waste management and then were
altered to prioritise patient equipment. The Team have since re-focused and patient placement is being given
priority, although this is not stated in the report.
There is also variation, across NHS Grampian, with regard to the quality and consistency of action plans and
how these are escalated when required.
The recommendations were discussed and decided upon in conjunction with Alison Hardy and are being taken
forward by the Joint Nurse meeting that PEH attends. At Woodend General Hospital the recommendations are
being taken forward by the HAI Group.
EM fed back that the information compiled from audits is very useful but is all forwarded to her for collation.
Unfortunately due to limited time it is now no longer a manageable task therefore this exercise needs to become
a process. Clinical Effectiveness have been approached for this assistance but unfortunately, due to manpower
issues, they are unable to help.
Amanda Croft, Alison Hardy and Elinor Smith need to be involved in this matter and PEH and RSD will meet to
discuss this.
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PEH / RSD/
EM
Date of next meeting
2 June 2014 (rescheduled) 11.00 – 13.00, The Conference Room, MacGillivray Centre, AMH
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