Document Sample
					                                                                                Agenda Item No. 12.2

                                 THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST

                            HELD ON THURSDAY 29TH OCTOBER 2009

Present:            Mr D Loughton (Chair)            (Chief Executive)                               (DL)
                    Mr J Vanes                       (Non-Executive Director)                        (JV)
                    Ms C Etches                      (Director of Nursing & Midwifery                (CE)
                    Prof. R Fitzpatrick              (Director of Pharmacy)                          (RF)
                    Ms S Roberts                     (Hotel Services Manager)                        (SR)
                    Ms S Harper                      (Infection Prevention Nurse)                    (SH)
                    Dr J Odum                        (Medical Director – Division 2)                 (JO)
                    Dr G Martinelli                  (Consultant – Cardiothoracic)                   (GM)

In Attendance:      Ms J Sharp                       (Occupational Health Manager)                   (JS)
                    Ms G Evans                       (SHA representative)                            (GE)
                    Ms S King                        (Matron Representative)                         (SK)
                    Ms K Bowley (Part)               (Matron)                                        (KB)

Apologies:          Dr M Cooper                      (DIPC)                                          (MC)
                    Mr B G Millar                    (Medical Director)                              (BGM)
                    Ms V Hall                        (Chief Operating Officer)                       (VH)
                    Ms J Taylor                      (HCAI Programme Lead – SHA)                     (JT)
                    Dr A Phillips                    (Director of Public Health – WCPCT)             (AP)

2.               Minutes of Meeting held on 24th September 2009

                 The minutes were accepted as a true record.

3.               Matters Arising from the Minutes

                 No items from the minutes were raised.

4.               Occupational Health Update

                 JS gave details of the current situation, the main points being:

                 Needlestick Incidents
                 28 Needlestick incidents June-August 2009. European Hospital and Healthcare
                 Employers’ Association have signed an agreement on prevention of sharps
                 injuries. A Hotline message has been set up on X6222 to inform staff of the
                 procedure to follow in the event of sustaining a needlestick injury.

                 DL requested that suggestions from the Committee on how to reduce the number
                 of needlestick injuries by 20% per year be put forward.                                      ALL

                 Seasonal Flu Vaccines
                 OH nurses since 5 October 2009 have visited wards, departments, Grand Rounds,
                 Senior Managers’ Briefings to administer season flu vaccines. At 21 October
                 2009, 565 from a total 5383 staff have been vaccinated, although May/June figures

                                                     Page 1 of 10
                                                                    Agenda Item No. 12.2

     are to be added to the statistics. JS expressed concern at the low uptake in A&E
     and Paediatrics. There had been some complaints from some staff in these areas
     of adverse reaction to the vaccine. DL asked JS to ascertain from midwives what         JS
     reactions had been suffered. The overall level of uptake was considered
     unsatisfactory and DL asked that JS keep him updated daily on the situation. The
     vaccine programme will continue until December 2009 as necessary. The OH
     team will make provision for out of hours staff and will attend the doctors’ forum on
     12 November 209 to administer vaccinations.

     DL to meet with Christopher Watkins, Trust Secretary, and JS to decide how best         DL
     to communicate the importance of the vaccination.

5.   Environmental Report

     SR reported:

     Deep Cleans:
     The programme for 2008/09 concludes at the end of September 2009.
     Outstanding areas are:

         High Risk Areas:        Ward D5
                                 Ward C5

     In response to a query from DL, SR reported that the reason Radiology had not
     undergone a deep clean was due to an issue around PFI and concerns about
     access to areas where equipment is located. DL said he would take up this matter        DL
     personally with Anthony Leese, Head of Radiology Services.

     The new deep cleaning programme for 2009/10 commences in October 2009 for
     very high risk areas.

     Technical Audits
     Over the last nine months an electronic auditing system has been used involving
     hand held PDAs. Results of the data collected are available on the summary sheet
     circulated to the group.

     There were no ‘red’ areas. The following in-house scores were achieved during
     the period 31.08.09 – 27.09.09:

     Very High Risk Areas: 91%        Good              (yellow)
     High Risk Areas:        98%      Excellent         (green)
     Significant Risk Areas: 94%      Good              (yellow)

     Use of Shower Curtains
     The Environment Group had reviewed the use of shower curtains and decided:

     -     Remove where possible and use door screens to ensure patient dignity.
     -     New shower curtains to be replaced quarterly as a minimum.

     The content of the report was accepted by the Committee.

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                                                                 Agenda Item No. 12.2

6.   Divisional Reports

     Division 1:

     GM reported:

     ‘Red’ areas on the scorecard related to antibiotic prescribing training in Urology,
     Ophthalmology, Head & Neck; device-related HABS in Oncology/Haematology and
     ICCU. GM felt that the scorecard was showing incorrect information and would
     speak to Ruth Horton (Service Improvement Department)

     The HII1 (Peripheral IV cannula care bundle) also showed non compliance by
     Oncology/Haematology. GM reported on discussions with Dr Simon Hester and a
     Physiotherapist, when it was considered that an RCA type document should be
     completed where there is HII non-compliance to assist in discovering if infections
     were being transferred from other areas. GM was keen for this process to then be
     shared across the Trust in the form of mandatory training. CE considered the
     suggestion a good idea in principle and that ANTT training around line insertion was
     key and would have a significant effect on all infections.

     GM, JO and MC to discuss the practicalities and benefits introducing such a system     GM/JO/MC
     outside of the meeting and report back to IPCC at a future date.

     The RCA summary relating to 1 x C.Difficile in ICCU was noted.

     Areas of focus over the next month:
        ICCU – new chart devised to be trialled during microbiology round
        ICCU – reusable masks ordered.
        Cardiac – replace fabric covered chairs
        Cardiology Ward – introduce clipping prior to procedure
        Urology – use of cleaning tags
        Haematology/Oncology – hand hygiene training

     Division 2:

     JO reported:

     The RCA summaries relating to 4 x C.Difficile (1 x ESS, 2 x D16, 1 x D19 and 1 x
     MSSA - NNU) were noted by the Committee. JO commented that the RCAs were
     now much more robust and the Head of Nursing had arranged for Matrons to sign
     them off.

     The scorecard showed several ‘red’ areas:
     •  Antibiotic prescribing training non-compliance: D7, D8, ASU, D15, D16, RDU,
        D18, Paediatrics and Neonates. The push to get junior doctors through this
        training continues.
     •  Device-related HABs: D5, D16, RDU, Neonatal Unit
     •  HII1 (CVC Catheter Bundle) and HII2 (Peripheral IV cannula care bundle) both
        relating to Neonatal Unit.

     It was agreed that a section for ANTT (Asepsis Non Touch Technique) training             CE
     compliance be included on the scorecard.

     Areas of focus over the next month:
     •  Quality of RCA documentation and action plans. The need to sign off by Matron
        has been discussed at Division 2 Sisters and Matrons meeting

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                                                                    Agenda Item No. 12.2

     •   MRSA care pathway ready for trial on D20.              Awaiting pathway and
     •   ANTT training to be rolled out
     •   Antibiotic prescribing training
     •   Hand hygiene – nurses. IP to roll out trial of WHO 5 moments observational tool
         – to be completed weekly until end of December 2009

     The Divisional Reports were noted by the Committee.

7.   Pharmacy Report

     RF reported:

     Division 1
     Use of cefuroxime and ciprofloxacin has fallen substantially since 2007, mainly due
     to initiatives aimed at reducing c.diff infection rates, and encouragingly use remains
     low. Use of the carbapenems has increased.

     The use of ciprofloxacin has increased since August, but is above average for use
     over the preceding 12 month period. ENT required ciprofloxacin for the treatment of
     pseudomonas aeruginosa infection. Oncology used ciprofloxacin for cholangitis, who
     was allergic to penicillin, under the advice of a Microbiologist. The vascular
     department prescribed ciprofloxacin for a patient with a pancreatic abscess under the
     advice of a Microbiologist.

     The use of meropenem has reduced since August but is above average when
     compared to the previous 11 months. Haematology used meropenem to treat a
     patient with CNS pseudomonas aeruginosa infection.

     Use of cefuroxime has increased since August and is above average when
     compared to use over the preceding 11 months.

     Use of ertapenem fell in September and use is below average when compared to
     use over the preceding 11 months.

     The use of amoxicillin and co-amoxiclav is now being monitored more closely to
     ensure use of the penicillins is appropriate and justified. With the general plan being
     to use amoxicillin then co-amoxiclav followed by reserved use of
     piperacillin/tazobactam.       Use of co-amoxiclav and piperacillin/tazobactam are
     generally falling but use needs to be monitored closely to ensure they are not being
     used first line, if not suitable.

     Action Points
     • Pharmacists are checking that patients with community acquired pneumonia
         receive amoxicillin first line and not co-amoxiclav.
     • Pharmacists will continue to focus on the use of carbapenems, due to concerns
         of resistance developing.

     Division 2
     The use of cefuroxime and ciprofloxacin has fallen substantially since 2007, mainly
     due to initiatives aimed at reducing c.diff infection rates, and encouragingly use
     remains low. Use of the carbapenems has increased, this is mainly due to the
     reduction in use of the cephalosporins and quinolones and partly due to improved
     identification of penicillin allergic patients thus cautiously using the carbapenems in
     these patients.

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                                                               Agenda Item No. 12.2

The use of ciprofloxacin has increased since August, but is below average for use
over the preceding 12 month period. A&E treated a number of patients presenting
with epididymo-orchitis and prostatitis with ciprofloxacin. Admissions treated a
patient with a salmonella infection, under the advice of a Microbiologist.

The use of meropenem has reduced since August and is below average when
compared to the preceeding 11 months. Admissions treated a patient with an ESBL
UTI under the advice of a Microbiologist.

Use of cefuroxime reduced since August, and is below average.

Use of ertapenem reduced since August, and is below average.

The very high peaks in the use of amoxicillin are related to the robotic device in A&E
being filled, this usually occurs every few months.

Action Points
• Pharmacists are checking that patients with community acquired pneumonia
    receive amoxicillin first line and not co-amoxiclav.
• Pharmacists are continuing to query the use of all cephalosporins and

Antibiotic Interventions for September 2009

The total number of reported interventions is 122 over the month of September, a
slight increase compared to last month. The antimicrobial pharmacist started to visit
wards with colleagues in October, to advice and support on antimicrobial prescribing

The majority of interventions involved the: treatment duration (25%), choice of drug
and whether it was for a suitable indication (20%) and dose prescribed (15%).

Treatment Duration
Pharmacists are challenging the treatment durations of antibiotics and stopping
where necessary.     In September prolonged co-amoxiclav, flucloxacillin and
trimethoprim courses were stopped (usually after discussion with a member of the
medical team).

Choice of antimicrobial/indication
Pharmacists are checking that antibiotics prescribed match up with the Trust
Antimicrobial Prescribing Guidelines. Co-amoxiclav prescriptions were queried and
changed to amoxicillin where appropriate. Erythromycin prescriptions were queried
and changed to clarithromycin.

Doses of antimicrobials
Antibiotics can be sub-therapeutic or toxic if not prescribed at the correct dose. The
Antimicrobial Prescribing Guidelines specify doses, thus Pharmacists are checking
that the dose prescribed is appropriate. The doses of trimethoprim were amended
(confusion between prophylactic and treatment doses), intravenous and oral doses
were also confused for co-amoxiclav.

Allergy Boxes
A patient on D15 had a penicillin allergy written on their T.S. but they were prescribed
and given 5 days of amoxicillin. A patient on the admissions ward was prescribed
co-amoxiclav when they had an un-documented penicillin allergy.

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                                                               Agenda Item No. 12.2

Action Points
• Pharmacists checking allergy status of patients on admission, where time allows.
• Pharmacists checking that penicillin allergic patients are not prescribed
    inappropriate antimicrobials.
• Pharmacists endorsing prescriptions of co-amoxiclav and piperacillin/tazobactam
    with contains penicillin.

Outcome of Interventions
There is outcome information for 70% of the recorded interventions, an increase on
previous months. Pharmacists are trying to ensure that whenever outcome
information is available that the detail is added onto the intervention sheet. Follow up
is difficult when patients are discharged or move wards. 64% of the known outcomes
involved the Pharmacists advice being taken and the Pharmacist dealt with the query
themselves in 21% of the recorded known outcomes.

New Initiatives
The updated antimicrobial prescribing guidelines (revised by Microbiology and
Pharmacy) are due to be published in November.

Antimicrobial prescribing stickers will be in use throughout the Trust at the beginning
of November (copy of the actual size prescribing sticker and the associated
prescribing poster attached to master copy of the Minutes)

Regional Data
The Antimicrobial Pharmacist works closely with the WMAPG (West Midlands
Antimicrobial Pharmacist Group) on auditing prescribing and sharing information
across the region. Across the region on the same day, pharmacists carry out a ‘point
prevalence audit’ of almost every inpatient. Information collected includes:
    • Completion of allergy status data
    • Whether the patient is on antimicrobials
    • Are they on IV antimicrobials
    • Duration of antimicrobial, if greater than 5 days is it appropriate
    • Is the stop/review date recorded on the chart

Information is then tabulated as in the attached table which summarises the results of
the July audit. Results summarised below are for 11 Trusts in the Region.

                       Summary of Results from July 2009 Audit
       Audit Measure                  New Cross versus the average result
 Number of patients             447 patients out of a total of
 audited                        3587. NX had the 2nd highest
                                number of patients included,
                                an achievement as we are not
                                the 2nd largest Trust.

 % of patients on antibiotics   26.4% at NX versus an average of 28.1%. Thus
                                fewer of our patients are on antibiotics.

 % of patients on IV            13% at NX versus an average of 12.9%.
 % of patients on antibiotics   49.2% at NX versus an average of 45.8%.
 on IV antibiotics

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                                                              Agenda Item No. 12.2

 % with allergy status         91.9% at NX versus an average of 96.1%. Some
 recorded                      Trusts in the region have electronic prescribing,
                               which insists the allergy box is completed prior to
                               the prescription being saved, thus the average is
                               quite high.

 % of patients on              28.8% at NX versus an average of 30.4%. Fewer
 antimicrobials where total    of our patients are on prolonged antimicrobial
 course >5 days                courses.

 % of patients on              82.4% at NX versus an average of 81.3%. More of
 antimicrobials where total    our patients on prolonged courses are on
 course >5 days                appropriately long courses.
 % of patients where IV        56.9% at NX versus an average of 59.5%. Fewer
 antibiotics > 48 hours        of our patients are on prolonged IV antimicrobial

 % of patients where stop      23.7% at NX versus an average of 62.9%. This
 or review date                measure is a new audit measure, thus is being
 documented                    tackled at the moment, see action points below. As
                               other Trusts have electronic prescribing inclusion of
                               a review/stop date is compulsory, thus the average
                               is quite high.

DL asked if Pharmacy had an action plan to identify the Trust’s status against these
indicators and ways of improving the Trust’s position in the league table. RF to bring   RF
an action plan showing a named individual against each action to the next meeting.

Action Points
• Pharmacists checking that all antimicrobials prescribed are necessary and in line
    with the Trust Antimicrobial Prescribing Guidelines.
• Pharmacists checking that patients are changed from IV to oral as soon as
    appropriate to do so.
• Pharmacists are completing the allergy box where possible.
• Pharmacists are checking the appropriateness of all prolonged courses in line
    with the Trust Antimicrobial Prescribing Guidelines.
• Pharmacists will be rolling out the antimicrobial prescribing stickers in early
    November; the sticker asks for the stop/review date to be stated when an
    antimicrobial is prescribed (see new initiatives). This information can then be
    used by Pharmacists to stop or review antimicrobials.

The Pharmacy report was noted and accepted by the Committee.

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                                                                     Agenda Item No. 12.2

8.   Performance

     CE talked to the DIPC report in the absence of MC:

     SPCC charts relating to September 2009 had been circulated to the group and were

     No MRSA bacteraemias during September. For the first time the Trust had gone an
     entire quarter without an MRSA bacteraemia. On 21st September it had been 120
     days since the last MRSA bacteraemia, and as at the date of this meeting there had
     been no instances.
     Only one MSSA bacteraemia attributable to RWHT in September, and only two in
     total for Wolverhampton. Still over target for MSSA bacteraemias, but we are now
     moving back towards the target rather than further from it.
     MRSA acquisition is only just within target for each Division and for the Trust overall.
     Although VSU had two cases, these were the first they had had since January 09,
     which was considered a magnificent performance from what was once one of the
     highest risk wards. D16 remains a problem, though their total was less than in
     August. D15 has also had a problem with this in September. The IPT has been
     working with these wards to help resolve any issues that might have contributed to
     C. difficile infections were at their lowest since February 2009, with five cases
     attributable to RWHT according to internal definitions and three cases using the DoH
     definition. Against our Trust internal target, although we remain above the target, it is
     of note that the Trust is moving closer to the target; at one stage it was 10 cases
     over, but now five cases over. D16 had two cases during the month, but there is no
     apparent connection between these, which occurred more than three weeks apart.
     Overall scorecard for the Trust and Divisions is totally green, but MRSA acquisition
     was very close to yellow.
     ESBLs were again high in the community. CE commented that the worrying aspect               GE
     regarding ESBL is that it is not fully understood. GE agreed to arrange a mapping
     exercise to establish more information. DL asked that it be noted how disappointed
     he was with the lack of progress around the necessity to reduce ESBLs, and it was
     unacceptable for the Trust to be in a position where incidents of ESBLs are not
     Hand hygiene data for September was not yet available.
     Hand hygiene training remains static at 82%. Only three groups of staff are hitting
     the target of 85%, but a further four groups fall between 80 and 85%.
     Antibiotic prescribing is low, but recently there have been several well attended
     sessions, so this should see an increase next month. Compliance among senior
     medical staff is 95% in both Divisions.
     Much better month for blood culture contaminants, with Paediatrics having six,
     compared with 12 last month.
     20 HABs, with 11 DRHABs, therefore within target. Lines are the predominant cause
     of DRHABs, with at least six and possibly eight due to lines. CE expressed concern
     that lines were part of the problem. Neonatal Unit gives the appearance of being a
     problem area, but there are many unique difficulties with diagnosing and attributing
     these infections, and much of what is stated as best practice in the care bundles are
     not relevant to this group of patients.

                                         Page 8 of 10
                                                                    Agenda Item No. 12.2

9.    Health Economy Infection Prevention Forum – Terms of Reference

      CE referred to the document circulated to the group – ‘Care Acquired Infection (CAI) :
      Strategic Wide Arrangements and Committee : Terms of Reference. The document
      required approval of the IPCC prior to presentation at Trust Board. DL and CE will
      be members of the Committee. It was agreed that the document should go to
      December 2009 Trust Board.

10.   Report of LNIP

      SH reported:

      Outbreaks / Incidents
      Nil to report

      Audit and Surveillance Activity
      Sharps practice and PPE audit report in progress for next meeting
      Isolation audit report attached

      MRSA admission screening
      Emergency admissions: 94%
      Elective admissions: 96%. CE asked SH to identify the reason for 4% elective             SH
      admissions not being screened.

      E learning package further problems from IT therefore not released for general use.
      DVD replaced training sessions to support redeployment of non clinical staff through
      September –November 2009.
      Five moments updates provided for Matrons and cardiology prior to launch of
      observational tool.

      Nil new to report

      TSE under review
      Appendix to Isolation policy for Renal Dialysis (attached)

      RRP 1 product being used in theatres (Sept - Nov) by cardiac, colo-rectal and
      vascular surgeons.

      Quality Compass
      The contract for use of the system will cease 31/10/09. Evaluation report to be
      generated with input from NHS Technology Adoption Centre.

      ATP Bioluminescence
      Loughborough University have approached RWHT to undertake a study to ascertain
      what frequency and test points are required to use such a system optimally.

      LoTrache ET Tube Study
      A meeting had recently taken place and proposal for the study was discussed; in
      principal Chris Gush is encouraged at the potential of the proposed study. Proposal
      to be generated for submission to Showcase Hospital programme for review.

                                          Page 9 of 10
                                                                    Agenda Item No. 12.2

      CE asked SH to explore the possibility of a trial of non-touch gel dispensers when the   SH
      contract for the current dispensers expires, to improve hand hygiene. JV reported
      that the current dispensers drip gel after use which could prove hazardous.

11.   Any Other Business

      11.1 Acoustic Tracking System
           CE informed the meeting that Paul Cryer (DoH) was looking for a site to
           implement the Acoustic Tracking System and had arranged a presentation at
           the Trust for today. The system tracks patients requiring isolation in the Trust.

10.   Date of Next Meeting

      Thursday 26th November 2009, 10.00am, Conference Room, Hollybush House.

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