NHS GRAMPIAN
Infection Control Committee
Minutes from meeting held on 13 November 2013
The Conference Room, MacGillivray Centre, Aberdeen Maternity Hospital
11.00 – 13.00
Present:
RSD - Dr Roelf Dijkhuizen, Medical Director
PEH – Pamela Harrison, Infection Prevention and Control Manager
KDW – Karen Wares, Nurse Consultant - HAI
NES – Noha El Sakka, Microbiology Registrar
JW – Juliette Watson, NHSG Decontamination Lead
GB – Gladys Buchan, Operational Lead Nurse, Aberdeenshire CHP
MY – Mandy Young, Operational Support Nurse Manager
EM – Eleanor Murray, Divisional Lead Nurse, Acute Sector
SC – Sean Coady, Community Health Services Manager, Moray
AMK – Anne Marie Karcher, Infection Prevention & Control Doctor
LM – Leonora Montgomery, Public Forum Representative
GM – Gary Mortimer, General Manager, Facilities & Estates
FD – Frances Dunne, Senior Service Manager
AS - Anneke Street, PA to Infection Control Manager (Minute taker)
1 / Introduction and Apologies /
Apologies were received from :
Elinor Smith (ES) Jenny Gibb (JG) Jane Adam (JA) Alexander Mackenzie (AM) Roy Browning (RAB)
Johnathon Lofthouse (JL) Emmanuel Okpo (EO) Sandy Dustan (SD) Keith Thomson (KT)
Sandy Thomson (ST)
2 / Minutes of last meeting
25 September 2013 /
The minutes from 25 September 2013 were ratified by the Committee with no amendments. / AS
3 / Matters Arising
Item 3.1 /
Roles and Responsibilities for Equipment Short Life Working Group
GM has prepared an SBAR for the Committee and spoke to this report.
The SBAR was produced with regard to the recommendations made by the HEI on their recent visits to Aberdeen Maternity Hospital.
Recommendation 1 surrounded the cleaning of patient equipment and beds. GM feedback that there has been substantial work started regarding this with the introduction of “bed busting teams” to deal with “on ward” equipment and bed space cleaning on patient discharge or as soon as cleaning need is identified. The estimated time for each bed space has been set at a maximum of 45 minutes and this equates to 32 WTE band 2 staff. Nursing staff are modelling this average against bed occupancy at present. This pilot follows a similar and successful model already in place at Dr Gray’s Hospital, Elgin. Health and Safety are also working with the Short Life Working Group to risk assess the 45 minute time recommendation.
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Matters Arising cont….
Item 3.2 / Recommendation 2 follows on with the development of a dedicated “thorough clean / maintenance team” to deal with “off ward” cleaning and dismantling of patient equipment, where it has been identified by the “bed busting team” ,that a more complex clean is required. This team will be led by an Estates maintenance team and a suitable location has been sourced within Aberdeen Royal Infirmary. Again Health & Safety are working with the Short Life Working Group to risk assess a 2 hour turnaround time recommendation.
Recommendation 3 depends on the outcome of an audit being completed and surrounds the possible need for a specific role regarding the monitoring of overall cleanliness. If deemed necessary, it has been suggested that this could be a “housekeeper” type role but with a clearly defined focus on cleanliness; this resource could be shared across wards / areas.
Recommendation 4 suggests that Senior Charge Nurses / Midwives are given a clear empowerment role and the responsibility for the environment which they oversee. This would include having the ability to direct and prioritise the efforts of the domestic staff working within their area. Domestic and Nursing staff have been advised of this new “line direction” and its outcome will be monitored closely by the Short Life Working Group.
Recommendation 5 realises that education and communication are the key elements to success in these new initiatives therefore the Infection Prevention and Control Team will be supporting all staff involved directly and will advise on any cleanliness issues identified.
GM stated that the main challenges around these recommendations will be resources.
KDW reinforced that the Infection Prevention and Control Team would continue to support the “bed busting” teams and that a successful new way of working has been achieved by “buddying up” a Nursing Assistant with a Domestic. This ensures that the teams are ready to react at every discharge. There are still issues with old equipment but staff are appreciative of the new way of working.
The most challenging issue is surrounding recommendation 5 as there is no National Guidance on “how” to clean a piece of equipment. The Infection Prevention and Control Team have supplied training to the bed busting teams with regard to cleaning in light of this.
GB feedback that she attended a local Support Services meeting recently incorporating the Shire and Royal Cornhill Hospital. The feedback from this meeting was very encouraging and staff have taken on the initiative.
GM confirmed that integration and communication across NHS Grampian has been good and confirmed that the Steering Group would be taking this initiative forward from the Short Life Working Group.
KDW also informed the Committee that Annette Rankin has confirmed there will be an A to Z Equipment Cleaning template released in the near future.
The Infection Control Committee accepted the recommendations made by the Short Life Working Group and RSD will take them to the Operational Management Team after they have been ratified by the Budget Steering Group.
Quality Assurance Short Life Working Group
RSD began by pointing out that despite all the efforts and work implemented surrounding roles and responsibilities these are still not clear to staff. NHS Grampian’s audits must be on a par with the HEI inspector’s views of the cleanliness of the environment to ensure cohesion. A collaborative approach with the HEI would be the ideal but unfortunately this is not achievable.
PEH informed the Committee that this subject has now fragmented and now has 3 branches.
The Quality Assurance Short Life Working Group met and began a consultation on proposals to commence “back to the floor” sessions across the Acute Sector. The Infection Prevention and Control Team, have now / RSD
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Matters Arising cont…. / implemented these sessions with a focused approach on checking outcomes. From the meeting it was, ultimately decided, that integration into the Acute Sector’s own “back to the floor” visits would be preferable; Alison Hardy is looking into this.
The second branch has been surrounding the Executive Team looking at Quality Assurance models. Alan Gray has scheduled a meeting on 18 November 2013 to look at Quality Assurance processes surrounding internal audits.
The last branch concentrates on Domestic and Estates monitoring and the cleanliness of the environment.
GM confirmed that there was on site support from Health Facilities Scotland looking at how monitoring could be aligned at a National level. PEH agreed that, unfortunately, the level of internal scrutiny was not on a par with the HEI’s. Feedback is required and the current system needs to be able to expand to deal with any changes that are made.
RSD stressed that accountability requires to be explained and described . This needs to be discussed with Exemplar wards. PEH to discuss this with JL.
Workshops are imminent and PEH and KDW are to attend.
RSD also posed the question of Infection Prevention and Control Team Quality Assurance audits – would these be completed every year for every area and how would these areas be prioritised? Health Protection Scotland suggest each area is quality assured once a year and prioritisation should be based on audit results.
PEH confirmed that prioritisation will be based on local audit results, if a problem is found then that area will be visited first. The plan is then to visit areas who consistently score 100% in audits to quality assure this information. Other reasons to visit and prioritise areas include outbreaks and non compliant hand hygiene audits.
EM raised the issue of the term “ward / clinical area” where this may not be representative of all areas within the Acute Sector and, who do not class themselves as “clinical”. This could be a risk to NHS Grampian if not looked into.
AMK suggested that all areas be defined as “clinical” to ensure that this is no longer an issue and thus incorporating all areas including wards.
RSD requested EM prepare a paper, in the form of an SBAR, explaining these issues in greater depth and naming the areas concerned.
GM also stressed that it was important to know who was leading these audits in each area, effectively the custodian. This needs to be clear and documented.
AMK felt that is was important that all staff were aware that the Infection Prevention & Control Team’s quality assurance audits were just that, quality assurance and that they will only be “checking the checking” of the audits already performed by the staff within that area.
RSD felt that the next Committee meeting date was too far away not to progress with this and asked that a paper be written and everything documented as soon as possible.
PEH to amend the diagram for the next Quality Assurance Short Life Working Group meeting on 18 November 2013 and to summarise audit results.
SC concluded by enquiring as to whether the Exemplar Ward would be rolled out for all areas within NHS Grampian in time. RSD replied that this would have to be discussed and decided upon through the Management structure. / PEH/JL
PEH/KDW
PEH
EM
PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Matters Arising cont…
Item 3.3 / Aberdeen Maternity Hospital - HEI Improvement Plan
PEH spoke on the report.
The Executive Team have been meeting weekly for updates and the agreed action plan had come to the Infection Control Committee to update members on progress so far.
There were 7 requirements set by the HEI and the outstanding issues are :
Requirement 1 – Undertake review on current audit tool used in Theatres to ensure it captures best practice
The Infection Prevention and Control Team have prioritised Theatres and visited several on 13 November 2013.
Requirement 2 –Review the content of all HAI policies to ensure they are compliant with the National Infection Prevention and Control Manual
This was the out of date document that the HEI discovered and it was withdrawn from use.
NHS Grampian have been awaiting national work to be completed on the Equipment Cleaning Standard Operating Procedures. This work has now been done but is still unapproved.
KDW stated that NHS Grampian were also still waiting for Annette Rankin to come back to provide support on implementing the A to Z Cleaning of Patient Equipment. When this is complete the Infection Prevention and Control team will take this forward, prioritising Aberdeen Maternity Hospital in the first instance.
Requirement 3 – Review the availability of alcohol hand gels in Ashgrove Ward
The Infection Control Committee were to take forward the Board wide decision on the use of end of bed dispensers. A risk assessment approach must be taken on this and a review of the literature from 2007. A risk control notice is also required.
Requirement 4 – Ensure all staff adhere to the HPS national Infection Prevention and Control Manual – Appendix 5 – Glove use and selection.
This recommendation was made due to the use, in some areas of NHS Grampian, of polythene gloves which should have been withdrawn. This has been addressed. GM has dealt with this through the PECOS ordering system and these gloves can no longer be ordered. The Divisional General Manager for Aberdeen Maternity Hospital has written to all staff with the instruction that these gloves are not to be used from this point forward and a risk control notice (formalised by the Infection Prevention & Control Team in conjunction with Annette Rankin) is in development.
Feedback will be given to Andrew Wood.
Requirement 5 – Ensure that staff implement SICPs for linen management in Neo Natal Unit
The washing machine previously in place has been replaced and the new machine will be calibrated to ensure correct optimum temperature is achieved during cycles. This will be closely monitored.
Requirement 6 – Demonstrate that expressed breast milk is stored appropriately and that documentation reflects best practice
New fridges have now been purchased and updated procedures compiled which state that temperatures must run between 2 and 4 degrees Celsius.
Monitoring of the temperatures of these fridges is included in the area’s environmental audits and non compliance with this will be actioned by management during back to the floor walkrounds. Mechanisms are now in place.
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Matters Arising cont… / Requirement 7 – Ensure that patient equipment is clean and that the procedure is understood by staff and fully implemented
Beds within Labour Ward are being reviewed with regard to using the best manufacturer available.
Domestic cleaning schedules have been reviewed and signed off by Domestic Services and the review to clarify roles and responsibilities for the cleaning of patient equipment has been completed by the Equipment Cleaning Short Life Working Group; this is now being reviewed by the Budget Steering Group and the Operation Managenemt Teams.
Processes and training on how to clean a mattress from top to bottom have been rolled out to the Neonatal Unit and Labour Ward with the help of a technical DVD from Clinell; this will now be taken forward locally.
Recommendation A – Ensure Senior Charge Nurses and Charge Midwives have accountability for Ward cleanliness
Laura Gray will circulate a Global email from JL regarding accountability by 18 November 2013.
Recommendation B - Ensure all staff understand and implement the Patient Placement Tool in line with local policy
The tool was trialled in the Neonatal Unit and considered unsuitable for the area and therefore AMK and the Infection Prevention and Control Team are to attend a meeting arranged to discuss amendments on
14 November 2013
Recommendation C - Review storage areas in the Neonatal Unit
This is ongoing monitoring through “back to the floor” walkrounds and environmental auditing.
Recommendation D – Contact Health Protection Scotland to discuss and review the use of sterile polythene gloves in Clinical areas and its compliance with the National Glove Selection policy
This has been completed under Requirement 4.
Recommendation E – Ensure all staff understand and implement the “checklist for discharge bed space cleaning for nursing staff” in line with local policy
Information is being gathered from “back to the floor” activity with regards to the revised checklist being implemented. The Neonatal Unit are developing a specific version to account for the difference in bed space equipment. / Laura Gray
AMK / IPCT
Item / Subject / Action to be taken and Key Points raised in discussion / Action
4 / Standing Items
Item 4.1
Item 4.2
Item 4.3
Item 4.4
Item 4.5 / Sector Reports
These reports were submitted to the Committee but not discussed at this meeting.
HAI Work Plan 0213/14 (for information)
This report was submitted to the Committee but not discussed at this meeting.
Risk Control Plan (for discussion)
This report was submitted to the Committee but not discussed at this meeting.
Health Protection Scotland Exception Reports (non since last meeting)
No reports to discuss
MRSA Screening Compliance
The verbal update on this was not given at this meeting
5 / Reporting to Clinical Governance Committee & Board
Item 5.1
Item 5.2 / HAI Report to the Board (aka HAIRT)
This report was submitted to the Committee but not discussed at this meeting.
HAI Report to the Clinical Governance Committee
This was not discussed at this meeting
6 / AOCB / GM queried whether the issue of Waste Management had been added to the HAI Work Plan as yet?
PEH answered that this report had not yet been updated but will be shortly.
8 / Date of next meeting /
28 January 2014 11.00 – 12.30 in the Board Room, Aberdeen Royal Infirmary
1