NHS GRAMPIAN
Infection Control Committee
Minutes from meeting held on 25 September 2013
The Conference Room, MacGillivray Centre, AberdeenMaternityHospital
10.30 – 12.30
Present:
RSD - Dr Roelf Dijkhuizen, Medical Director
PEH – Pamela Harrison, Infection Prevention and Control Manager
KDW – Karen Wares, Nurse Consultant
DOB – Dr Deirdre O’Brien, Infection Control Doctor / Medical Microbiologist
AM – Dr Alexander Mackenzie, Infectious Diseases Consultant
GB – Gladys Buchan,Operational Lead Nurse, Aberdeenshire CHP
PM – Dr Pamela Molyneaux, Consultant Virologist
KT – Keith Thomson, Head of Health & Safety
EM – Eleanor Murray, Divisional Lead Nurse, Acute Sector
SC – Sean Coady, Community Health Services Manager, Moray
DW – Diana Webster, Consultant, Public Health Medicine
AMK – Anne Marie Karcher, Infection Prevention & Control Doctor
LM – Leonora Montgomery, Public Forum Representative
RAB – Roy Browning, Senior Infection Control Nurse
GM – Gary Mortimer, General Manager, facilities & Estates
KT- Katherine Targett, Consultant Occupational Physician, Occupation Health
AS - Anneke Street, PA to Infection Control Manager(Minute taker)
1 / Introduction and Apologies /
Apologies were received from :
Jane Ormerod (JO) Elinor Smith(ES) Pamela Molyneaux (PM) Juliette Watson (JW) Helen Robbins (HR)
Gillian Macartney (GMac) Frances Dunne (FD) Jenny Gibb (JG) Jane Adam (JA) Sue Swift (SS)
2 / Minutes of last meeting
17 July 2013 /
The minutes from 14 May 2013 were ratified by the Committee with slight amendments to members present. / AS
3 / Standing Items
Item 3.1 /
Sector Reports
Acute
EM spoke to this report and informed the Committee of a new area of concern surrounding Environmental Inspections and walk rounds not always being carried out on a regular basis; this is a pertinent issue in light of recent HEI Inspections. Divisional teams within the Acute sector are taking responsibility for this and ensuring that processes are in place.EM also fedback that since this report was written “back to the floor” sessions have now become mandatory for Management Teams to carry out.
Other risks previously reported and still classed as a very high level of risk were :
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Standing Items cont… / Hand Hygiene Compliance – learning outcomes form recent Problem Assessment Groups need to be reviewed
and shared across the Acute sector.
PVC Insertion and Maintenance Bundles not being implemented in every clinical area – further audits are needed surrounding this,together with consistent documentation.
Aberdeenshire CHP
GB spoke to this report and informed the Committee of a new area of concern surrounding a failed Hand Hygiene audit within an area of a CommunityHospital. Issues remain regarding Hand Hygiene and the Dress Code being adhered to by clinical staff. A Problem Assessment Group meeting was held on 11 September. Actions completed include Hospital Medical Directors and Clinical Leads being contacted with guidance surrounding the policies; they will be distributing this to their clinical colleagues and adding this issue, as an item, to the Clinical Services Group agenda to discuss processes should staff groups continue to be non-compliant. A second Problem Assessment Group meeting will be held at the end of October.
Other risks previously reported were :
Implementations of SEWS – the planned action was to ensure training and use across all areas. This has now been implemented in all Community hospitals and the level of risk is now considered to be low.
Community Hospitals being prepared for an HEI Inspection – a second round of 3 monthly audits have been completed and there has been improvement in all audited areas. Action and Improvement Plans are in place, Assurance Team visits have been completed to two hospitals with positive results and the Aberdeenshire HAI Group has been convened and regular monthly meetings are taking place. The level of risk on this issue has now been reduced to medium.
National Influenza Vaccination Schools Programme – here the concerns were regarding the Sharps boxes, their disposal and School Nurses transportation of them. Risk Assessments have been completed, no incidents have been reported and as NHS Grampian employees, it has been confirmed, that nurses are licensed to carry them.
Areas of Achievement –improved communication and support from Estates and Facilities staff and continued team work with Support Service staff surrounding the Domestic Monitoring Tool and Exception Reporting system.
Aberdeen City CHP
Work is ongoing at WoodenedGeneralHospital in preparation for an HEI inspection and this is still considered a high risk issue. Actions being undertaken include collation for information to ensure correct processes / audits are in place, Quarterly Infection Control meetings being held, processes have been devised and agreed regarding environmental being undertaken and action plans created.
Areas of Achievement – include all Estates HEI requirements logged timeously and escalated if problems persist, an audit implementation of the SOP for cleaning re-usable equipment has been completed and the majority of areas achieved 100% and much improved communication. Working with Support Services regarding domestic sign off and exception reporting has also been accomplished.
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Standing Items cont…
Item 3.2 / Mental Health
No report was received.
Facilities and Estates
GM spoke to this report discussing previously reported risks.
Water Safety
A risk control notice had been issued with regard to Pseudomonas in high risk areas – CEL(08)2013 and it was felt that this places more responsibility on nursing staff within these areas to take daily action and record evidence with regard to compliance with the CEL. It was felt that compliance with CEL requirements could be monitored via the existing ward based audits for an initial period of 3 months and any gaps would be discussed and escalated as necessary. This level of risk has been lowered to medium.
Waste Management
There are, unfortunately, increasing incidents of non compliance with areas of waste management (segregation, storage and security) and the following of the waste policy which are not always recorded on DATIX as would be expected. A global email has been issued clarifying PPE disposal in the clinical waste stream, waste disposal training has been implemented and progressed and a waste audit is planned Grampian wide by an independent specialist contractor.
GM asked for the waste disposal training to be added into the HAI Work plan.
PEH will update the report.
Areas of Achievement – include good feedback from the HEI inspectors with regard to staff awareness on pseudomonas requirements specific to the Neonatal Unit, on a recent unannounced visit to AberdeenMaternityHospital
Moray CHP
Sean Coady spoke to this report discussing previously reported risks.
Hand Hygiene non compliance
This issue was addressed through the Clinical Director and Clinical Leads and a problem Assessment Group meeting was held. Learning from this meeting will be shared and a follow up review meeting is due to be held.
The level of risk has now been lowered to medium.
Areas of Achievement – include unannounced audits ongoing and Moray Community hospitals are now undertaking a review of mattresses and equipment.
HAI Work Plan 2013/14
RSD asked for updates to the Work Plan
Delivery Area 1
1.2 – Development of infection prevention guidance in relation to emerging threats from antimicrobial resistance
AM fedback that this action was “on track” but due to staffing issues it has been difficult to progress and there / PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Standing Items cont… / have been delays in reporting and training.
RSD will speak to David Phleger regarding staffing to enquire as to whether this is a planned reduction in staff.
Date of last update to be amended to September 2013
Delivery Area 2
2.3 – Develop and Implement a standardised system for cleaning of patient care equipment
It was felt that the lead on this action required updating. PEH to update
Delivery Area 3
3.1 – Development and implementation of a single audit tool to assess compliance with opportunity and technique of hand hygiene
This action is progressing and AberdeenMaternityHospital has recently started inputting their results onto the LanQip system. The Infection Prevention and Control Team will support them until the end of October 2013.
3.5 – National Infection Prevention and Control guidance will be reviewed and updated as necessary
PEH is to liaise with Juliette Watson (JW) with regard to the NHS Grampian action 3.5.2 – recommendations around the decontamination of medical devices
3.7 – Prioritise key policy and guidance for Infection prevention and Control in Community settings
DW informed the Committee that this guidance was still under development at National level and was proving problematic. Thechapter onClostridium difficileInfections has just been commenced therefore, at present, local policies are still being used for guidance and implementation.
Date of last update requires to be September 2013
3.12 – Development and implementation of education and training on aseptic technique
AMK drew the Committee’s attention to the SBAR circulated which was compiled by Catherine Mitchell and headed ANTT Implementation.
The launch of this is due in November 2013 and Catherine Mitchell has organised an educational event, to be held at Royal Aberdeen Children’s Hospital, which will introduce key trainers to the framework and allow them to concentrate on individual aspects of ANTT that are relevant to their clinical environment.
AMK also fedback that Orthopaedics have been approached regarding involvement and both James Bidwell and David Boddie are interested.
Delivery Area 4
The actions noted here are still awaiting National Guidance
Delivery Area 5
5.3 – Review of Infection Prevention & Control Competencies required
PEH is to liaise with the HAI Education Group to discuss the topic of job descriptions in relation to NHS Grampian’s action 5.3.2
5.7 – Development of surveillance and epidemiology skills and capacity at NHS Board level
PEH is to update the Lead column for this action / RSD
PEH
PEH
PEH/JW
PEH
PEH
PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
3 / Standing Items cont…
Item 3.3
Item 3.4 / Delivery Area 6
PEH confirmed that she has prioritised the upgrade of ICNethere.
The Infection Prevention and Control Team now have experience of Quality Improvement methodology aftereitherreceiving training or through participation in quality improvement project. In addition, funding has been made available by the Scottish Government to recruit an HAI Quality Improvement Facilitator.
Delivery Area 7
7.7 – Continuing development and support to the National MRSA Screening Programme
This is still included in the report due to continued difficulties with data collection.
7.9 – Further explore the true prevalence of Staphylococcus aureus bacteraemias and Clostridium difficile Infections within the Community
At the present time only one local meeting has been held but there has been a reduction in MSSA bacteraemias and Health Protection Scotland are impressed with the work carried out to date.
7.14 – Development of invasive device surveillance
This task has been superseded by the CVC and PVC bundles implementation.
Risk Control Plan
This report was not discussed at this meeting
Health Protection Scotland Exception Reports
There have been none since the last meeting
4 / New Business
Item 4.1 / HEI Inspection of AberdeenMaternityHospital
RSD spoke on this agenda item informing the Committee that since the initial, unsatisfactory, HEI inspection a further 2 have taken place. The second visit found the areas of concern (regarding cleanliness of specific areas) were slightly improved and the third visit found the inspectors to be pleased with the work undertaken and the cleanliness much improved.
There was good practice noted in the report but criticisms included internal quality assurance systems (documentation lacking) and reporting to the Infection Control Committee and the Board.
RSD and Pauline Strachan have met to look into quality assurance issues not being prioritised within high risk areas; not enough is being done surrounding this. The Infection Control Committee must look into this and improve ways of working. There must be some form of decision on priority areas and that standards are maintained within them; self assessments must be performed and further scrutiny is needed to ensure that this system is working. / PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
4 / New Business cont… / GM felt that the domestic audits being performed are not looking far enough into the cleanliness of an area. Areas may look clean but staff must look further than this into this and find opportunities where cleanliness is lacking; more attention to detail is required. There is also still confusion around roles and responsibilities for patient equipment cleaning and decontamination. There was a suggestion that an NHS Grampian wide,short life working group be convened to discuss these issues and provide solutions. It is expected that GM will chair this group along with Alison Hardy and it will report back quickly to the NHSG Infection Control Committee and the Senior Management Teamson decisions made and policies put in place. RSD agreed that this was the way forward and that the Short Life Working Group should feedback to the Committee by the end of October.
EM agreed this group would be beneficial as the general nursing view, following the inspection, is one of confusion. This needs to be made absolutely clear to staff and a briefing paper is being compiled by Alison Hardy.
The exemplar ward is another initiative that is being launched at present and Hazel Whyte is leading on this.
RSD feels that this new initiative will bring much clearer guidance and information to staff in one single portfolio which will be relevant to their ward / area and will be assimilated for NHS Grampian as a whole.
GM voiced concerns over the sustainability of audit results due to being under resourced and EM requested the views of the Committee regarding their confidence in the 3 monthly audit process.
The general consensus was that more work was required surrounding staff’s understanding of the audit tool and more clarity into the process.
RSD suggested that it may be helpful,in prioritised audits, to have a member of the Infection Prevention & Control Team present to participate directly, resulting in a more focused approach to the audit.
KT suggested that this would be beneficial to support services staff.
PEH to lead on dovetailing audits with Domestic staff audits
PEH informed the Committee that she had been collating information, from other Infection Control Managers, about their quality assurance processes and confirmed that no board, to date, had one. The information received had surrounded audits, around varying subjects, that their infection control teams carried out.
RSD asked that AberdeenMaternityHospital are prioritised regarding this and stressed that a short timeline should be applied on this exercise.
The discussion ended with the information that the HEI Inspection Report would be published late October / early November.
/ GM
PEH
PEH
5 / Reporting to Clinical Governance Committee & Board
Item 5.1 / HAI Report to the Board
RSD asked that the Aberdeen Maternity Hospital HEI inspection be added to this report with cleaning compliance as a footnote.
RSD and PEH will meet to update the report prior to its submission to the Board at the November 2013 meeting. / RSD/PEH
Item / Subject / Action to be taken and Key Points raised in discussion / Action
5 / Reporting to Clinical Governance Committee & Board cont…
Item 5.2 / AMK also fedback on Staphylococcus aureus bacteraemia levels explaining that the “spike” in numbers in
June and July 2013 were on a par with the same period in 2012.
NHS Grampian’s rates are favourable to other Scottish Boards although the HEAT target has been slightly missed this year.
Clostridium difficile infection numbers have also shown a reduction due to the good work of all involved.
HAI Report to Clinical Governance Committee
This was not discussed
6 / AOCB / AM raised theoccurrence of a patient recently admitted who had been residing in Nigeria and may have been a Viral Haemorrhagic Fever risk. Guidelines were distributed to all front line staff and guidance was followed correctly. In conclusion, the virus laboratory latterly confirmed that there was no virus present.
8 / Date of next meeting /
13 November 2013 11.00 – 13.00 in the Conference Room, MacGillivray Centre, AberdeenMaternityHospital
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