Infection Control Committee Meeting Minutes Nov 2011
NHS GRAMPIAN
Infection Control Committee
Minutes from meeting held on 15th November 2011
The Conference Room, Dugald Baird Centre, AMH
10.00 – 12.00
Present:
Dr Roelf Dijkhuizen, Medical Director, NHSG
Gillian Macartney, Specialist Antibiotic Pharmacist
Roy Browning, Senior Infection Prevention and Control Nurse
Kathy Coutts, Theatre Manager, RACH (deputising for Alan Pilkington/Mary McAuley)
Stewart Rogerson, Head of Soft FM Services (and Decontamination Lead) (attending for Gary Mortimer)
Gladys Buchan, Lead Nurse, North Aberdeenshire LCHP
Jenny Ingram, Patient Safety Programme Manager
Dr Alexander MacKenzie, Consultant in Infectious Diseases
Eleanor Murray, Unit Nurse Manager (deputising for Vince Shields)
Jane Ormerod, Head of Professional Development (and HAI Education Lead)
Tommy Ovens, Public Forum Representative
Karen Wares, Local Health Board Co-ordinator
Sandy Thomson, Lead Pharmacist, Dr Gray’s Hospital, Moray (deputising for Andrew Fowlie)
Caroline Hind, Development Pharmacist
Anneke Street, PA to Infection Control Manager (Minute taker)
1 / Introduction and Apologies /
KDW opened the meeting and apologies were received from :
Pamela Harrison Pamela Molyneaux Gary Mortimer Elinor Smith Lynn Young Alan Pilkington
Amanda Croft Vince Shields Anne Marie Karcher John Brett Jane Adam
2 / Minutes of last meeting
13th September 2011 /
Minutes from the meeting 13th September 2011 were ratified with the following amendment.
A typo was found on page 7 – Surgical “Sight” Infection was amended to Surgical “Site” Infection.
3 / Matters Arising /
3.1 TB Incident Report – Education
There was no feedback on this agenda item as no one was present to feedback to the Committee.
This item had been added to the agenda at the request of RD who wished the level of awareness to be kept up. The negative press publicity over a recent incident was disappointing and RD felt that education was the key to minimising future incidents.
Item / Subject / Action to be taken and Key Points raised in discussion / Action
4 / Standing Items / 4.1 Surveillance Report (HAI-RT)
The HAI Report was submitted.
The Committee requested page numbers to be added to this report.
RAB summarised the report which showed that, across NHSG, there were no reported MRSA bacteraemias in August or September. Clostridium difficile cases fell by 2 in August but rose again by 4 in September; however the downward trend over the last 12 months is being maintained. The latest Hand Hygiene monitoring figures shows 98% compliance; cleaning compliance also remains consistently high at 94% (4% above the National target). Estates monitoring (by domestic staff) was introduced in April 2011 and compliance figures can be found in this newly formatted scorecard.
The new “Totals SAB” graph is included and shows a slight rise in Staph aureus bacteraemias in August and September but the trend, overall, is downward over the last 12 months.
Aberdeen Royal Infirmary
Within Aberdeen Royal Infirmary there was an increase in Clostridium difficile infections which rose to 6 in September but the yearly downward trend is still being maintained. There were 3 cases of MSSA bacteraemias in August and September; however this is 2 below the annual average of 5 Cleaning compliance remains high at 94% since April 2011 and the newly available estates monitoring data shows compliance at 90% since the monitoring commenced. Hand Hygiene also remains high at 95% in August.
Dr Gray’s Hospital
A 100% compliance rate for Hand Hygiene was achieved in August. Compliance rates for cleaning and estates monitoring are in the process of being extracted at present; so far data is available back to July. Cleaning compliance remains very high at 98%, the National target being 90%.
The first case of Clostridium difficile, since October 2010 presented in August and a further single case arose in September. There were also 2 cases of MSSA bacteraemias in August but no MSSA or MRSA bacteraemias in September.
Woodend Hospital
A 100% compliance rate for Hand Hygiene was achieved in August.. Clostridium difficile infections remain stable at between 0 - 2 per month over the last year.
There were 3 MSSA bacteraemias in September but only 1 case of MRSA bacteraemia in the last 12 months.
As predicted, cleaning compliance has returned to target or slightly above since July. This is due to the recruitment of extra domestic staff and estates monitoring figures show that compliance is low but has been rising steadily since May.
Community Hospitals
This heading incorporates many hospitals due to their size and infection numbers being low – AMH, RCH, RACH and Roxburgh House are all included in addition to the hospital within the Shires.
There were 3 cases, in total, of Clostridium difficile in August occurring at Aboyne and Fraserburgh Hospitals and Roxburgh House and single cases of MSSA bacteraemias in August and September were reported at Royal Aberdeen Children’s Hospital. No MRSA bacteraemias have occurred in this group since September 2010.
Out of Hospital
The number of cases of Clostridium difficile presenting out with hospital or within 48 hours of being admitted have dropped to an 8 month low in August but rose again in September; although a downward trend can be seen over the last 12 months. MSSA bacteraemias rose slightly in August and September (an increase of 1 case per month) but a downward trend can also be seen here. There have been no MRSA bacteraemias since April 2010.
It was fedback to the Committee that there was now an indentified roll out programme surrounding decontamination with a single operating procedure now being rolled out across NHSG. The tagging system used to identify clean equipment has now been ceased and the responsibility has fallen to senior staff nurses to quality assure the cleanliness of each piece of equipment regularly.
The SAB90 group met again at the beginning of November to search for a way forward for the future. Key discussions were surrounding the proposed ownership from clinical areas and the gaps that require to be dealt with.
ST pointed out that the C-diff graph for Dr Gray’s does not show the September infection. PEH to amend.
GB asked if the scorecard for Community Hospitals could be made clearer with regards to the fact that Shires Hospitals are also included in this category. She also clarified that one of the Clostridium difficile infections was found to have originated within a Fraserburgh GP surgery with regards to antimicrobial prescribing and the 4 Cs. A report was written on this by Catherine Mitchell – Infection Control Nurse.
RAB informed the Committee that the MRSA Community protocol was with the HPT, comments have been sent in.
HEAT Targets
NHS Grampian exceeded, slightly, the Staphylococcis aureus bacteraemia HEAT target for April – June , as published in the Health Protection Scotland Quarterly report on 5th October. NHS Grampian’s rate was shown as 0.403 episodes per 1000 acute occupied bed days (AOBDs), compared with NHS Scotland as a whole where the rate was 0.309.
The MRSA bacteraemia rate was 0.044 episodes per 1000 AOBDs compared with 0.040 for NHS Scotland as a whole and for MSSA bacteraemias the rate was 0.359 cases per 1000 AOBDs compared to 0.269 in NHS Scotland showing that both MRSA and MSSA bacteraemia rates were slightly higher than the national average for this quarter.
The HPS Quartely report on the surveillance of CDI showed that between 1st April & 30th June the reported rate in patients over 65 years old in NHSG was 0.27 episodes per 1000 total occupied bed bays (TOBDs). This was lower than NHS Scotland as a whole which was reported as being 0.31.
GM queried how HPS are obtaining occupied bed days data when NHS Grampian are not able to. JI suggested this may be historical data and if so, this should be remarked upon in the report.
/ PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
4 / Standing Items cont… / Hand Hygiene
KDW feedback that NHS Grampian’s unverified data score is 99% (this relates to wards “combined” audits).
PEH to make clearer that only “technique” figures are being shown in the HAI-RT at present – not “combined”.
Cleaning and the Healthcare Environment
The NHS Scotland National Cleaning Compliance Report for quarter April - June shows NHS Grampian, as a whole, to be above 93% compliant. In Woodend Hospital the compliance has improved slightly to 87.4% and local figures for months July, August & September show compliance at 90%, 91% and 91% respectively.
The report also includes estates monitoring figures. Across all participating hospitals in NHSG compliance was above the 90% target at 92.5%
EM informed the Committee that then generic risk assessment tool for mattress cleaning is complete and has been signed off by VS. EM would like to now roll this out but queried whether this need to go to any other groups for authorisation prior to it’s commencement. JI suggested that the risk assessment be submitted to the Clinical Governance Committee for information and assurance and perhaps, also to Pauline Strachan and the delivery unit.
Outbreaks and Incidents
RAB confirmed that the posters for the winter virus (Norovirus) are being distributed across NHSG at present.
4.2 HAI Work Plan 2011/12
The HAI Work Plan 2011/12 was submitted.
This report was discussed at the last meeting..
4.3 Risk Control Plan
The Risk Control Plan was submitted
HSE G2.9 performance Management (Medium)
RAB confirmed that the SPC charts for SABs and C-diff are being sent out to managers on a regular basis.
There is still plenty of work a be done (and ongoing ) surrounding SABs.
QIS 3b.1 Compliance with Infection Control Policies (Medium)
The Policy group continues to meet to discuss and update policies and protocols. Once protocols have been signed off these are then available on the Infection Prevention & Control web page for staff to access.
There has been another Dress Code draft protocol circulated recently but the ongoing issue seems to be the wearing of “greens”, soiled or clean, in shops / canteens within the hospital and the public’s perception of this. Jill Ferbrache & Michael Coulthard are investigating this.
EM informed the Committee that the issue was not with theatre staff being called away to A&E or ITU but with the wearing of visibly soiled garments in public areas. EM and VS have discussed this and feel that there is no / PEH
PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
4 / Standing Items cont… / “buy in” at senior level for enforcement. Perhaps the Acute Management Team could provide
options/answers ?
KDW feedback that the Point Prevalence Survey highlighted not only the wearing of visibly soiled greens within
canteens / shops but also the wearing of surgical hats and masks.
PEH to add narrative on the dress code into the Gaps in Controls column.
QIS 3b.1 Audit and Surveillance (Medium)
KDW feedback that Hand Hygiene Audit implementation has been rolled out to Royal Cornhill Hospital.
The Action column should now be updated to include the hand Hygiene Standard Operating Procedures recently
distributed across NHSG.
QIS 3b.6 Risk Assessment and Patient Management (High)
The issue continues to be the Risk Control Assessment form. In Moray this is progressing well and a “mini”
quality assurance check was performed whilst the Point Prevalence Survey was being undertaken.
Mandatory Hand Hygiene training (e-learning) is ongoing and work around the new Standard Infection Control
Precautions package is progressing well with the deadline having been extended to December 2011.
QIS 4a.1 Cleaning (High)
The process of ensuring easily identifiable cleaned equipment is ongoing,.
QIS 4a.1 Cleaning (Very High)
The Committee were asked to reduce this risk level from Very High to High. It was also requested that this risk
needs be separated into 2 sections and reviewed – this has been rolled out in Acute and plans are imminant
To roll out In the Shires. PEH to separate the risk.
This action is complete and the outstanding action is the referencing to the Decontamination Protocol.
This risk was deemed very high as it was picked up by the HEI but he Standard Operating Procedures are now
used as the checklist at ward level.
Quality assurance and the Decontamination Protocol need to be added to the actions column.
KDW also remarked that the flowchart received from HPS, with regards to using 1,000 parts per million (ppm) of
Chlorine Releasing Agent, was incorrect. This should read 10,000 ppm and NHSG were the only Board to have
picked up on this error. The HEI have been informed.
QIS 4b.2 Procurement (Medium)
Continue to ensure that the Infection Prevention & Control Team are aware of any new equipment being
bought in to NHSG in order to be able to give advice.
QIS 1a.7,2 Communication (Medium)
Joanne Grant – Infection Control Nurse has been working on a draft communication document but work on this
Was put on hold during the Point Prevalence Survey.
QIS 5b Education (High) & QIS 5a.1 (Medium) – page 13
KDW feedback that the proposed Articulate SICPs package in on course to complete by December 2011; it has
still to be aligned to the SICPs manual. PEH to amend the wording in the Controls column regarding Cleanliness
Champions. This course is now open to all NHSG staff not just band 6 & above. / PEH
PEH
PEH
PEH
PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
4 / Standing Items cont… / RD suggested that the training of staff should be at the leadership / ownership of managers and that once trained
AM feedback that the HEI suggested antimicrobial training for all medical staff but there remains the problem of
how to monitor mandatory training.
Training is achievable every 2 years and should be in Medical Staff’s PDP. Mechanisms of how to achieve this
need to be explored.
RAB suggested that he would like to discuss, how this training an be carried out in a productive way, with AM
and EM.
JO referred to the SBAR and feedback on the issue with medical engagement; the HEI are keen to pursue this. It
would be helpful if the Committee could support this.
AM replied that a paper has been circulated and online courses and dates are available; how can this be pushed
to PDPs ?
JO and AMK to approach Dr EM to discuss requirements and would the next step be to present to the
Clinical OMT ?
RD asked for a plan to be devised on what the training would involve with regards to prescribing and also asked
for a presentation to be submitted to him.
QIS 5a.1 Education & NHSG ICC 1 Organisational Practice (High) – page 14
All these risks are being actioned.
NHSG ICC 2 Organisational Practice (Medium)
The Committee were asked to consider reducing this risk to low with regard to new domestic staff having been
Trained at Woodend General Hospital.
RD queried why the CJD screening is not on the Risk Register. SR to liaise with PEH to amend this.
SR also feedback that there has been new NICE guidance released with regards to children born prior to 1997.
It is considered that these children have been, potentially, exposed to the risk of contracting CJD and therefore
could be carriers. The guidance states that separate instruments need to be available to these children when
Moving through to adult healthcare services. SR is representing NHSG on the ? Group and will feedback to the
Committee in due course.
4.4 Health Protection Scotland Exception Reports
There were no exception reports to discuss. / JO/AMK
SR/PEH
5 / New Business / 5.1 Education
JO explained the papers that had been submitted to the Committee.
These gave an overview of the HEI Education Group and its workings and the challenges of engaging with medical staff surrounding education. The workplan of the group is being reviewed and it must be ensured that it focuses on the right topics and continues to receive guidance from the Committee.
Within the topic of developing the role of the Cleanliness Champion JO posed the question – what happens after a member of staff completes the Programme and how can they aid the organisation with their newly learned skills. It was suggested that a template be made available, for managers to use in the development of practice within their own area, to share with senior charge nurses and ward managers and for feedback purposes. Cleanliness Champions should be being encouraged by their managers to take charge and to be made to feel valued and important within the organisation.
.
Item / Subject / Action to be taken and Key Points raised in discussion / Action
5 / New Business cont… /
The issue was how to approach the Champions initially .
RD agreed that the Infection Control Committee should support this initiative and managers need to be bale to show, within the Cleanliness Champion’s PDP, how they are going to utilise these staff to their full potential.
JI suggested uploading a 1 page SBAR onto the Intranet.
JO to continue to keep the Committee informed of the progress with this.
6 / Reporting to Clinical Governance Committee and Board / The HAI Report will be submitted to the Clinical Governance Committee and the Board along with a report on the recent HEI visit.
KDW also suggested an update be submitted to Clinical Governance surrounding the Standard Operating Procedure (SOPs) for Decontamination of reusable equipment. This is with regard to the work NHS Grampian has undertaken with Health Protection Scotland that is anticipated to be rolled out nationally.
RD and PEH to agree wording.
/ RD/PEH
6 / AOCB / Antimicrobial Team Annual Report
GMc raised the issue of the report attached for information and RD questioned whether this should go to The Board and the Clinical Governance Committee; this should be discussed by the Committee.
RD asked for the report to be an Agenda item for the next Infection Control Committee meeting.
Healthcare Waste
RAB feedback that he had recently been to a healthcare Waste Committee meeting and there was talk around changes that may have to be implemented.
The Scottish Environmental Protection Agency (SEPA.) is working towards the banning of macerated waste. The first phase of this will be food waste followed by other macerated waste.
There is also a proposal to segregate the contents of black bag waste at source. At present bags contain a mix of non clinical waste and the proposal is to identify & segregate the contents.
/ PEH
7 / Date of next meeting /
17th January 201, 11.00 – 13.00 The Conference Room, MacGillivray Centre, AMH
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