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1 documents attached have been password protected, if you require the password can you call me on the number below Regards Anne RQIA Announced Infection and Control Governance Inspection The Regulation and Quality Improvement Authority Belfast Belfast Health Health & Social & Social Care Trust Care Trust Announced Infection 3 March Prevention 2015 and Control Governance Inspection Augmented Care DRAFT 3 March 2015 Assurance, Challenge and Improvement in Health and Social Care

2 Contents Page 1.0 Inspection Summary 2.0 Overview of Inspection Tool 3.0 Inspection Findings: Regional Infection Prevention and Control Governance Audit Tool Criterion 1: Board Level Leadership to Prevent HSCAI s (Healthcare Associated Infection) Criterion 5: Environmental Cleanliness 3.3 Criterion 8: Admission, Discharge and Transfer 4.0 Summary of Recommendations 5.0 Key Personnel and Information 6.0 Announced Inspection Flowchart 7.0 Escalation Process 8.0 Quality Improvement Plan

3 1.0 Inspection Summary On the 3 March 2015 an announced inspection was undertaken to the Belfast Health and Social Care Trust (BHSCT). Details of the inspection team and trust representatives attending the feedback session can be found in section 5. The following three criteria were reviewed during this inspection: Criterion 1: Board level leadership to prevent HCAI s ( Healthcare Associated Infection) Criterion 5: Environmental cleanliness Criterion 8: Admission, discharge and transfer The inspection process included a self-assessment questionnaire completed by trusts. The process also included a review of submitted documentation, discussion with representatives from infection prevention and control, nursing, patient flow and support services. Inspectors also undertook spot checks in wards to independently verify information supplied by the trust as part of the self-assessment process. Overall the inspection team found evidence that the trust was working from board to ward to prevent the development and transmission of infection. The inspection team, throughout the process, identified close teamwork and sharing of information between the Infection Prevention and Control Team (IPCT), support services and nursing. These services are integrated under the remit of the Director of Nursing and User Experience. Further work is required with the Public Health Agency (PHA) to develop systems and processes for reporting and documenting HCAIs such as MRSA and Clostridium difficile. The inspection identified four recommendations, which should be taken forward at a regional level, and five recommendations for the BHSCT (Section 4). The final report and Quality Improvement Action Plan will be available on RQIA s website. If required reports and action plans will be subject to performance management by the Health and Social Care Board (HSC Board) and the PHA. RQIA s inspection team would like to thank the BHSCT and staff for their assistance during the inspection. 3

4 2.0 Overview of Inspection Tool Regional Infection Prevention and Control Governance Audit Tool - Organisational Systems and Governance Arrangements This Quality Improvement Tool is based on the National Institute for Health and Clinical Excellence, Quality Improvement Guide, Prevention and Control of Healthcare Associated Infections (2011). The tool contains 11 criteria and can be used by the Health and Social Care trust (HSC trust), as well as those working in private, voluntary and community sectors and the wider public. The criteria statements aim to help build on previous guidance to improve the quality of care and practice over and above current standards. The quality improvement statements contain guidance and describe excellence in care and practice to prevent and control Healthcare Associated Infection (HCAI). The Governance Tool is not subject to a scoring system. Organisations will use this tool as a self-assessment. It is envisaged that all criteria will be reviewed within the three-year cycle of improvement. Criteria chosen for inspection will be agreed in consultation with HSC trusts. 4

5 3.0 Inspection Findings: Regional Infection Prevention and Control Governance Audit Tool For the purposes of this inspection report, the findings have been presented under the three criteria inspected. Criterion 1: Board level leadership to prevent HCAI s (Healthcare Associated Infection) Criterion 5: Environmental cleanliness Criterion 8: Admission, discharge and transfer 3.1 Criterion 1: Board Level Leadership to Prevent HCAI s (Healthcare Associated Infection) Trust boards demonstrate leadership in infection prevention and control to ensure a culture of continuous quality improvement and to minimise risk to patients. People visiting, or receiving treatment in hospitals can expect all trust staff, from board to ward level, to take responsibility, and be accountable for, continuous quality improvement in relation to infection prevention and control. Boards should work proactively in ensuring continuous quality improvement by leading on, and regularly monitoring compliance with, all relevant infection prevention and control objectives, policies and procedures. Trust Self Assessment The self-assessment submitted by the trust indicates that the trust board has an up to date working knowledge and understanding of infection prevention and control (IPC). The trust board has an agreed annual improvement plan on infection prevention and control. The Lead Director for IPC talks to these issues weekly at Executive Management Team meeting. IPC is the main topic on the Agenda for the Healthcare Associated Infection Improvement Team (HCAIIT), and IPC Committee/Safety and Quality Steering Group, Assurance Group, Assurance Committee/Trust Board. The issue is the Trust s number one Primary Driver on the Safety, Quality and Experience Improvement Plan. Performance indicators are used by the Board to monitor the Trust s IPC performance under safety and quality within the performance report. These include Clostridium difficile and MRSA bacteraemia performance against the DHSSPS reduction targets. Directorates are provided with an update on the number of these isolates on a weekly basis to enable them to inform their local action plans which are reflected in the Trust HCAI Improvement Plan. In compliance with the Infection Control Controls Assurance Standard, the Trust has an IPC Steering Committee, which meets twice yearly. 5

6 The mechanism is to ensure compliance is managed within Directorates and reported at the HCAIIT by Directorate representatives. The trust promotes a self-governance culture for infection prevention and control from Board to Ward. Each Directorate Director is responsible for delivering on improvement targets for their respective Directorates, and are all called to account on their performance at mid-year and end of year Accountability meetings with the Chief Executive and Lead Director for Infection Prevention and Control. The trust has supported and promoted the Changing the Culture guidance from the Department of Health, Social Services and Public Safety (DHSSPS) Northern Ireland. Feedback from Ward/Department representatives from across the trust is given at the monthly Health Care Associated Infection Improvement Team meetings. Inspection Findings BHSCT documentation reveals a clear pathway of information flow to the trust board; this ensures that the trust board is up to date and has a working knowledge and understanding of IPC. The trust board has agreed an annual HCAI improvement plan, which outlines its corporate objectives on IPC leadership, communication, HCAI reduction and IPC training. Each directorate have developed their own HCAI improvement plan to deliver on the corporate improvement targets. Staff advised and documentation reviewed evidenced that, as part of implementing the directorate actions of the HCAI improvement plan, there is a clear accountability and feedback structure. IPC is a standard item on monthly directorate governance meetings, monthly ward sisters meetings and at local ward staff meetings. As part of the assurance process, members of the executive team participate on a schedule of leadership walk round sessions. These walk rounds are set on three specific criteria: safety, challenges and achievements. IPC under the criteria of safety is a component of each of these ward/department visits. Leadership walk rounds are reported via the Safety and Quality Steering group. The IPCT supports all walk rounds where appropriate. Visits by the executive team were validated on review of documentation and discussion at ward level. Inspectors identified a strong sense of multi-professional collaboration from all key stakeholders in delivering on the trust IPC improvement plans. The lead director for IPC (Director of Nursing and User Experience) chairs the HCAIIT meeting, which occurs on a monthly basis. Key representatives are from nursing, medicine, patient and client support services (PCSS), estates, microbiology, allied health professionals etc. Within the trust assurance framework structure, the HCAIIT is the key interface to facilitate, co-ordinate and drive HCAI improvement initiatives from board to ward level. The key duties of this team include leading on initiatives to embed IPC practices. 6

7 This ensures that learning from root cause analysis (RCA), audit, surveillance and outbreaks is communicated through the trust structures and appropriate actions taken. The trust also communicates with the PHA regarding HCAIs, health protection incidents and outbreaks. Reducing harm from HCAIs is the primary driver on the trust s Healthcare Quality and Safety Improvement Plan. There is a series of performance indicators used by the Board to monitor the trust s performance. These indicators include Clostridium difficile and MRSA bacteraemia. Trust performance against these targets is available on the BHSCT intranet site for all staff to access. Documentation reviewed and discussion with the lead IPC nurse identified that the trust has not achieved the targets for the reduction in MRSA bacteraemia and Clostridium difficile infection (CDI). It was identified that there is ongoing debate and some confusion surrounding peer group comparisons with healthcare trusts in England regarding interpretation of MRSA and C-difficile data. Peer comparisons have historically been based on using admissions data as denominator; admissions being the choice of denominator when PHA introduced the analyses in Peer analysis has continued to use this denominator (admissions) to facilitate comparisons over time. It is recognised that a number of denominators may be used to examine HCAI rates. Therefore, the PHA has undertaken an additional analysis to examine the rates of MRSA and CDI using total occupied bed days (OBDs) as well as hospital admissions. Since April 2013, data for MRSA bacteraemia is no longer reported using the timing of the infection. Rather a post infection review process is carried out for every MRSA bacteraemia, which is then assigned to the acute trust or the clinical commissioning group. The RQIA has subsequently met with the PHA. The PHA has agreed to meet with trusts, to provide further clarification and agree the way forward in relation to ongoing quality improvement in the reduction of MRSA and CDI. 1. It is recommended that trusts meet with the PHA to agree the way forward in relation to ongoing quality improvement in the reduction of MRSA and CDI. (Regional) Staff responsibility for IPC is a standard component of all job descriptions and is an integral part of the staff appraisal process. Inspectors identified that the IPC team are functioning under increasing pressures. The BHSCT have more critical care areas than any other trust within Northern Ireland, this has placed huge resource demands on the IPC team. Over recent months, the team have also had to manage an unprecedented number of outbreaks caused by resistant infectious organisms. 7

8 Limitations in staff numbers have meant that the IPC team are delivering a reactive service to infection rather than a proactive preventative service. These factors have significantly affected progress with the IPC team yearly strategy. 2. It is recommended that the staffing complement within the IPC team is reviewed to ensure a proactive preventative approach is taken to the management of infection. The trust has an IPC link nurse system in place, which supports the IPC team in their role as expert advisers and facilitators. However, inspectors were advised that the IPC link nursing staff based on the wards do not always have the protected time to carry out this role. Ward staffing pressures was cited as the primary cause for this. The DHSSPS document Changing the Culture 2006 identifies that link staff need to have dedicated protected time for their infection prevention and control activities. 3. It is recommended that IPC link nurses have protected time to carry out their role. Inspectors were informed that releasing staff from wards/departments to attend IPC mandatory training was increasingly difficult due to staff pressures. The IPC team is currently developing IPC e-learning modules specifically tailored for their target audience. The e-learning modules benefit the trust by being able to schedule training around work duties and reducing the travel time between sites to attend face-to-face training. Ward Observation All areas visited reported regular visits by senior management staff as part of environmental cleaning managerial walk rounds. Staff reported that they felt supported by their direct line manager who was present on a regular basis at ward level. Staff were aware and could reference leadership walk rounds carried out by the Director of Nursing, Executive team and Non-Executive trust board members. Leadership walk round visits were announced and centred on safety, challenges and achievements. Leadership teams met with staff, patients and reviewed the ward environment. Inspectors were advised that action plans had been developed for leadership walk round visits and discussed with staff at the ward meetings. All wards visited carried out a range of IPC audits which were displayed on their performance dashboard. Audits included compliance with care bundles, hand hygiene and environmental cleanliness. Performance data is disseminated to ward staff via team meetings and safety briefs. Action plans are developed for low compliance scores. 8

9 There are designated IPC nurses for each trust site. Staff advised that the IPC team regularly visits the wards and is responsive and supportive in providing training, advice and guidance. 3.2 Criterion 5: Environmental Cleanliness Trusts ensure standards of environmental cleanliness are maintained and improved beyond current national guidance. People visiting, or receiving treatment in hospitals can expect care settings to meet high standards of cleanliness, with each trust monitoring the condition of its premises to ensure levels exceed the minimum required standard. Boards ensure policies, procedures and resources are in place to maintain and continuously raise the level of cleanliness across the trust. Trust Self Assessment The trust s organisational arrangements for ensuring and maintaining high standards of environmental cleanliness in pursuit of providing for a safe and clean healthcare environment are in congruence with the provisions of the Cleanliness Matters Strategy and Cleanliness Matter Tool Kit Although the reference period for this regional strategy lapsed in 2008, the trust has continued to apply its provisions until such times as the review of the strategy was completed. The trust participated in the statutory consultation process in advance of the revised Policy for the Provision and Management of Cleaning Services in the HSC Sector being published on 15 January Environmental cleanliness practices reflect those detailed in the Healthcare Cleaning Manual 2009 or regional guidance in circumstances where this exists e.g. clinical hand wash sinks. Where shortfalls in cleaning frequencies have been identified, the trust has submitted an Investment Proposal Template to the HSC Board/PHA in pursuit of securing the necessary funding to increase cleaning frequencies in line with the NPSA National Specification for Cleanliness in the NHS in the hospital healthcare environments in the first instance. Notwithstanding this, the trust has increased cleaning frequencies by way of a risk-based approach in areas where increased incidents of HCAI have been identified through surveillance monitoring arrangements. The trust is cognisant of the most recent version of PAS 5748 and the risk based approach advocated as the way forward in terms of cleanliness in healthcare facilities. This alongside the recently published regional policy and associated action plan sets the scene for many changes in the approach to the provision and management of environmental cleanliness in healthcare. The trust s has in place a range of standard operating procedures, policies and protocols in respect of environmental cleanliness/decontamination. These vary in accordance with the risk classification attributed to each area/locations in terms of cleaning practices and frequencies. 9

10 Additionally these policies and procedures identify roles and responsibilities for cleaning/decontamination of elements by discipline. Since the creation of the BHSCT, roles and responsibility for elements have in the main been standardised. Where standardisation has not yet been realised legacy roles and responsibilities continue to exist. However, the trust continues to work towards standardisation across all healthcare settings/facilities but some elements necessitate detailed levels of consultation with a wider range of stakeholders and a realignment of resources accordingly. Following the publication of the Cleanliness Matters Strategy all trust facilities/locations/rooms were risk assessed in order to assign a healthcare environment risk classification namely; [1] very high risk, [2] high risk, [3] moderate risk and [4] low risk. These assessments were used to inform the development of cleaning specifications, schedules and cleaning methods for each functional area proportionate the relative risk. These risks have remained relatively static with the exception of a number of areas, which are now identified as augmented care areas following incidents of pseudomonas aeruginosa in December 2011 January The trust has in place an annual audit programme of departmental and managerial audits as required by the Cleanliness Matters Toolkit; these audits focus on 49 environmental cleanliness elements. The trust has in place additional monitoring arrangements to measure compliance with audit frequencies and this is one of a suite of key performance Indicators for support services personnel. The trust uses Maximiser software to undertake these audits, which provides the capacity to undertake statistical analysis of environmental cleanliness scores and audit frequencies. Additionally the software provides for identifying audit failures for corrective action. The data captured is published widely on a monthly basis and the report provides a dashboard style report of compliance for display at departmental/ward/functional area. Presently the trust is at an advanced stage of implementing a new monitoring/audit software system; namely C4C. Where previously the Maximiser software included the 49 elements defined in the Cleanliness Matters Toolkit the new C4C software provides the opportunity to put in place monitoring and auditing arrangements predicated on the Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool, which provides for a much more detailed audit of healthcare cleanliness and hygiene. This coupled with the opportunity to review audit frequencies as per the revised Policy for the Provision and Management of Cleaning Services in the HSC Sector will provide for an enhanced level of monitoring. In circumstances where an environmental cleanliness audit fails to meet the required standard the report provides the basis for the necessary corrective action. Additionally a repeat audit is undertaken as a follow up measure until the audit outcome achieves the required level of compliance. In circumstances where increased incidents or an outbreak situation is identified the history of audit scores will be reviewed during the Outbreak Control Meetings alongside other relevant patient profile information etc. 10

11 As a first response, environmental cleaning frequencies will be enhanced in line with the recommendations of Microbiologist and Infection Prevention & Control colleagues and where appropriate this will include deep cleaning and VHP procedures. Enhanced cleaning frequencies will remain in place until such times as the increased incidents or outbreak status is stood down by Consultant Microbiologist and Infection Prevention & Control Team. The findings of these repeat audits will inform discussions at outbreak meetings during the outbreak status. Additionally reference material is readily available and/or displayed as appropriate in each area/location. An information folder containing the aforementioned is included in each location for ease of accesses and this includes COSHH data sheets for products available together with other relevant information. All newly appointed environmental cleanliness personnel are provided with appropriate induction training in order to equip them with the necessary knowledge and practical skills required to fulfil their duties and responsibilities. Additional/refresher training is provided as necessary where skills and/or competencies fail to meet the required standards. In the event of changing practices or the introduction of new cleaning practices or equipment, the necessary training is provided to all personnel. Despite best efforts to engage patients/clients/carers in environmental cleanliness monitoring programmes this continues to be an area for the trust that requires further development. It has been the trusts experience to date that this group of stakeholders are hesitant to become involved by virtue of the formalities that exist around the monitoring process. The trust does have a Patient Experience Working Group and there have been instances where information obtained has been useful in gauging feedback in respect of the cleanliness of the healthcare environment in which we deliver our services. In recent months, the Trusts Nursing & User Experience Directorate has introduced a Planning, Performance & Innovation function which will enhance the directorate s statutory requirement for Personal Public Involvement and how patients, clients, service users, carers and communities are involved and contribute to the environmental cleanliness agenda in Health and Social Care. Additionally the 10,000 voices initiative provides an opportunity for service users to channel feedback in respect of services provided. Inspection Findings The trust s has in place a range of standard operating procedures, policies and protocols in respect of environmental cleanliness/decontamination. These policies and procedures identify roles and responsibilities for cleaning/decontamination by specific discipline. 11

12 There is an annual audit programme of departmental and managerial audits. Departmental audits are carried out on a weekly basis with the ward/dept., sister or manager. A multi professional team approach is taken to managerial audits. The team includes an IPC nurse, PCSS cleaning team and a representative from the estates department. Members of the IPC team are not always able to attend due to other work commitments. 4. It is recommended that a member of the IPC team is available to attend managerial audits. Maximiser software is used to undertake these audits. This software provides the capacity to undertake analysis of environmental cleanliness scores. These audits focus on 49 environmental cleanliness elements. The software allows for the quick development of the audit report, which identifies audit failures for corrective action. Inspectors were informed that audit reports are displayed in a dashboard style for public viewing within wards and departments throughout the trust. We note that the trust intends to replace the Maximiser software with a new audit software system; namely C4C. C4C software will allow for monitoring in line with the Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool. Where increased incidents or an outbreak of infection has been identified, environmental cleaning frequencies are enhanced in line with advice from the Microbiology and IPCT. This includes deep cleaning and decontamination by vapourised hydrogen peroxide (VHP) procedures as necessary. Enhanced cleaning frequencies remain in place until such times as the increased incidence or outbreak status is declared over. Evidence provided by the trust had highlighted that an enhanced cleaning regime in a critical care area had continued after completion of an outbreak, as a continued infection preventative mechanism. An objective of the trust HCAI improvement plan is to promote patient and public involvement in IPC. Inspectors were informed that it has been challenging to establish patient representation at key IPC meetings and monitoring programmes. To date, the trust s experience is that this group of stakeholders is hesitant to become involved. The trust has used patient feedback from the 10,000 initiative to identify area of improvement in cleanliness within the trust Emergency Department. 5. It is recommended that the trust establishes patient representation at key IPC meetings and monitoring programmes All PCSS cleaning staff receives an induction programme. Induction equips staff with the necessary knowledge and practical skills required to fulfil their duties and responsibilities. IPC is a key element of induction and further training requirements. Topics of ongoing training included: IPC, waste segregation, sharps awareness, hand hygiene and personal protective equipment training 12

13 Inspection Observation The PCSS team report that they work closely with the IPC to ensure a high standard of environmental cleanliness. This is evident not only as routine practice but also in times of outbreak management. Key IPC stakeholders reported that the PCSS team is a valued member of the HCAIIT. In all areas visited, environmental cleaning results were above 95 per cent for January Cleaning audits are undertaken every four weeks with results displayed on ward white boards for staff, patients and visitors to view. Some cleaning audit results however were not always easily viewed and the results of hand hygiene audits were also not always available to view. 6. It is recommended that environmental cleanliness and hand hygiene audit results are clearly displayed for staff, patients and visitors to view. Ward staff reported that PCSS supervisors were regularly visible on wards. PCSS cleaning staff were responsive to all cleaning requests both inside and outside core working hours. 3.3 Criterion 8: Admission, Discharge and Transfer Trusts have a multi-agency patient admission, discharge and transfer policy, which gives clear, relevant guidance to local health and social care providers on the critical steps to take to minimise harm from infection. Patients with an infection can expect relevant information about it to be shared between providers when they are admitted, transferred to, or discharged from a hospital to ensure seamless care. Boards lead on the development of an agreed multi-agency admission, discharge and transfer policy. They ensure mechanisms are in place to support and monitor adherence to the policy. Trust Self Assessment Infection Control risk status is included in documentation used for admission and discharges. The Infection Prevention and Control risk status documentation is used by staff as part of the admission and discharge process, copies of which are kept in the patients notes. For all patients who are admitted from the Emergency Departments (EDs) a Risk Assessment form for potential infections is completed. If there is an actual or potential risk of infection, the patient flow team and receiving ward will be notified of this so that a suitable bed placement can be arranged for the patient to minimize risk of onward contamination. A risk assessment form is contained within the Ward Nursing documentation and should be completed for all admissions. 13

14 A separate IPC Risk Assessment form is used on transfer of a patient. The Nursing documentation has a section to note IPC issues on discharge. There is an IPC risk assessment form in Nursing documentation and a standalone form for use in ED and for each transfer. This is a regionally developed tool, which has recently been updated and circulated for use. The new Paediatric Nursing documentation booklet will also have the IPC risk assessment form included when it is printed. CPE policy reflects the measures to be taken with regard to sharing this information with patients and healthcare staff. BHSCT have developed a CPE card that patients can carry, as currently there is no regional method of identifying these patients between trusts. The BHSCT has a suite of tools for documenting and sharing information about infections and treatment. An example of some of these tools is listed for information as follows: IPC risk assessment form nursing discharge notes consultant letters admission medical records nursing admission booklet documentation MRSA/C Diff Pathway Inter Hospital Transfer policy PHA transfer form In addition, there are a number of communication pathways, which ensure that the patient s infection status is shared with relevant people as follows: Direct communication between Patient Flow teams and wards. Communication with patients/relatives who are advised of transmission based isolation precautions and nursing requirements as necessary. Daily nursing handovers/safety briefs includes infection status. Patient Infection status highlighted at ward rounds. Pre Op checklist include infection status communicated at handover between ward and theatre staff. Clinical summary between hospital teams includes infection status. Inter hospital checklist is completed for each patient which reflects infection status. IPC posters are clearly on displayed on wards. Patient and Visitor Information leaflets provided on ward/ departments. Discharge letter to GP/ District Nurse provides infection and treatment follow up. Electronic Care Record (ECR) includes consultant letter and access to microbiology results. Specific infections e.g. CPE triggers interagency case conference procedures. 14

15 Direct liaison between senior hospital team and community teams and General Practitioners (GPs) on discharge If a ward has a designated Pharmacist, they or the nurse will explain discharge medication to patient/relative and give advice on taking the antibiotic as per prescription. Medicine container reflects written advice and a leaflet may be provided to patient/relative. Discharge letter is sent to GP/ District Nurse and this provides infection status and treatment follow up. Electronic Care Record (ECR) includes microbiology results. The requirement of the management and cleaning of medical devices is assessed on an individual basis and based on the individual patients care needs. One to one advice is given were appropriate to patient and/or relative/carer on the management of a device which includes how it should be cleaned and maintained. Were appropriate information leaflets on specific devices provide cleaning instructions e.g. urinary, supra pubic catheters. Inspection Findings Inspectors identified a range of admission, transfer and discharge forms in use. The IPC admission risk assessment form, included within each Nursing assessment and plan of care booklet, is completed at ward level. In the ED, the IPC risk assessment form is a single sheet. Once completed the form and booklet accompany the patient throughout their hospital journey. On review of the new regional patient IPC Admission/Transfer Risk Assessment form, inspectors noted comprehensive patient information gathered. However, there was no instruction on when to complete the form and nowhere to record the updated risk assessment, the ward the patient was admitted/transferred to or the admission/transfer time. A robust system should be in place to ensure that staff are instructed when to use the form and the need to either retain a copy of the form or a record that the form has been completed. 7. It is recommended that the IPC Admission/Transfer Risk Assessment form be reviewed. A robust system should be in place to ensure that staff are instructed when to use the form and the need to either retain a copy of the form or to record that the form has been completed. (Regional) The BHSCT patient administration system (PAS) automates the admission and discharge information of inpatient, outpatient, and emergency department patient attendances. The trust currently has three patient administration systems: one for the Royal Group of Hospitals, the Mater hospital and one that combines both the Belfast City hospital and Musgrave Park Hospital. Each PAS can be used to alert staff if a patient has had a previous history of MRSA, however the system does not have the capacity to highlight other notable resistant organisms. 15

16 As the three systems do not interface with one another, the patient s MRSA history may not always be recorded on each of the three systems. The inspection team identified that the recently introduced regional electronic care record (ECR) system, in its current configuration, cannot robustly identify those patients with a previously diagnosed alert organism. This highlights that there is not a reliable regional method of identifying the infection status history of patients between trusts. Staff depend on information received from patients and relatives during the admission process. Patients with a history of CPE are asked to carry a card to identify this organism. This strategy is however isolated to the BHSCT. 8. It is recommended that the trust, with the PHA, further develop the use of the ECR to capture patients infection status. The ECR system should integrate with current IT systems, or where necessary one regional IT system, to capture all relevant patient information. (Regional) Antimicrobial stewardship and prudent prescribing is a key objective of the trust HCAI improvement plan. Corporate objectives include, antibiotic usage auditing with antimicrobial prescribing policies by pharmacy staff and medical staff on wards. Audit results are presented and reviewed at the trust s antimicrobial steering committee. In November 2014, the BHSCT launched an antimicrobial Microguide application, which is available on smart phones. The aim of the app is to provide an easy to use resource to support the antimicrobial prescribing decisions of medical staff. As outlined within Changing the Culture Strategy for Tackling Antimicrobial Resistance (STAR) , patients with specialised antimicrobial needs are increasingly being managed in the community, allowing otherwise fit patients to be discharged early from hospital. Appropriate prescribing of antimicrobials is essential across the interface between hospital and primary healthcare settings. It is estimated that approximately 80 per cent of antimicrobial prescribing takes place in the community. 9. It is recommended the trust liaise with the PHA to improve antimicrobial stewardship and prescribing in Primary healthcare settings. (Regional) Inspection Observation On discussion with patient flow, inspectors were informed that the IPC team was easily accessible to give advice and guidance as required. Risk assessment forms provide valuable information for patient flow in planning and assigning patients to isolation locations in line with the trust s isolation policy

17 Nine IPC risk assessment forms were reviewed at ward level; all were completed satisfactorily within the nursing booklet. Three of these patients were admitted via the ED however, two of the single sheet IPC risk assessment forms were not completed. In January 2015, an audit of the completion of the IPC Risk Assessment forms was undertaken. The audit highlighted that 87.7 per cent of forms were completed on admission. Highlighted areas of concern included: IPC Risk assessment forms were not always completed in the ED IPC Risk Assessment forms were not always completed on patient transfer IPC Risk Assessment form does not allow multiple entries Discussion with all staff indicated that the IPCT works closely with patient flow, hospital and community staff to ensure all patients with an infection are placed appropriately and safely to negate the risk of transmission. 17

18 4.0 Summary of Recommendations The Regional Infection Prevention and Control Audit Tool Criterion 1: Board Level Leadership to Prevent HCAI s (Healthcare Associated Infection) 1. It is recommended that trusts meet with the PHA to agree the way forward in relation to ongoing quality improvement in the reduction of MRSA and CDI. (Regional) 2. It is recommended that the staffing complement within the IPC team is reviewed to ensure a proactive preventative approach is taken to the management of infection. 3. It is recommended that IPC link nurses have protected time to carry out their role. Criterion 5: Environmental Cleanliness 4. It is recommended that a member of the IPC team is available to attend managerial audits. 5. It is recommended that the trust establishes patient representation at key IPC meetings and monitoring programmes. 6. It is recommended that environmental cleanliness and hand hygiene audit results are clearly displayed for staff, patients and visitors to view. Criterion 8: Admission, Discharge and Transfer 7. It is recommended that the IPC Admission/Transfer Risk Assessment form be reviewed. A robust system should be in place to ensure that staff are instructed when to use the form and the need to either retain a copy of the form or to record that the form has been completed. (Regional) 8. It is recommended that the trust, with the PHA, further develop the use of the ECR to capture patients infection status. The ECR system should integrate with current IT systems, or where necessary one regional IT system, to capture all relevant patient information. (Regional) 9. It is recommended the trust liaise with the PHA to improve antimicrobial stewardship and prescribing in Primary healthcare settings. (Regional) 18

19 5.0 Key Personnel and Information Members of RQIA s Inspection Team Thomas Hughes Sheelagh O Connor Margaret Keating Inspector Infection Prevention/Hygiene Team Inspector Infection Prevention/Hygiene Team Inspector Infection Prevention/Hygiene Team Trust Representatives attending the Feedback Session The key findings of the inspection were outlined to the following trust representatives: Mr M Dillon Ms K Welsh Ms G Traub Mr D Robinson Ms C Murton Ms I Thompson Ms J Buchanan Ms T Clinton Ms D Wightman Ms L Houlihan Ms L Crowe Ms L Taylor Ms J Sheridan Mr S Trainor Ms N Scott Ms R Bradley Ms S Norwood Ms L Mc Donnell Ms J Stewart Ms C Clarke Ms K Kerr Deputy Chief Executive BHSCT Director, Surgery and Specialist Surgery Acting Co-Director, Cancer and Specialist Medicine Co-Director Nursing, central Nursing Governance Manager Lead Nurse IPC Infection Prevention and Control Nurse Service Manager ICU, Anaesthetics ASM oncology Inpatients Assistant Service Manager Haematology Acting Clinical co-ordinator nephrology and Transplant Specialist Services Manager OSM ICU Planning and Performance Manager Senior Manager PCSS Senior Service Manager Environmental Cleanliness Ward Sister 11 North Acting Service Manager Deputy Ward Sister 10 North Deputy Ward Sister 11 North Ward Sister 11 South Apologies Dr Michael McBride Ms B Creaney Chief Executive BHSCT Executive Director of Nursing and User Experience 19

20 Notification of Inspection Plan Programme 6.0 Announced Inspection Flowchart Plan Programme Environmental Scan: Stakeholders & External Information Consider: Areas of Non-Compliance Infection Rates Trust Information Prioritise Themes & Areas for Core Inspections Prior to Inspection Year Balance Programme January/February Schedule Inspections Identify Inspection Team 6 weeks prior to inspection Notify organisation of inspection date and send draft programme and self assessment Make request for supplementary information from organisation eg: Policies & Procedures Management Audits Training Records Organisation advises of affiliate for inspection 3 weeks prior to inspection Organisation returns self assessment and supplementary information NO Is all information returned? YES IPHTeam analyse returned information IPHTeam identify areas to be inspected Prepare Inspection Team 1 week prior to inspection Notification of final on-site programme 20

21 Reporting & Re-Audit Episode of Inspection A Carry out Inspection Day of Inspection Day of Inspection Is there immediate risk requiring formal escalation? NO YES Invoke RQIA IPHTeam Escalation Process B A Feedback Session 14 days after Inspection Preliminary Findings disseminated Does assessment of the findings require escalation? NO YES Invoke RQIA IPHTeam Escalation Process B A 28 days after Inspection Draft Report disseminated 14 days later Signed Action Plan received from Trust Within 0-3 months Is a Follow-Up required? Based on Risk Assessment/ key indicators or Unsatisfactory Quality Improvement Plan (QIP)? YES Invoke Follow-Up Protocol NO YES Is Follow-Up satisfactory? Open Report published to Website NO Refer to DHSSPS HSC Board/PHA 21

22 7.0 Escalation Process B Invoke RQIA IPHTeam Escalation Process Concern / Allegation / Disclosure Inform Team Leader / Head of Programme MINOR/MODERATE Has the risk been assessed as Minor, Moderate or Major? MAJOR Inform Trust key contact and keep a record Inform appropriate RQIA Director and Chief Executive Record in final report Inform Trust / Establishment / Agency and request action plan Notify Chairperson and Board Members Inform other establishments as appropriate: Eg: DHSSPS, RRT, HSC Board, PHA, HSENI Seek assurance on implementation of actions Take necessary action: Eg: Follow-Up Inspection 22

23 8.0 Quality Improvement Plan Reference number Recommendations Action required Criterion 1: Board Level Leadership to Prevent HCAIs (Healthcare Associated Infection) Date for completion/ timescale 1. It is recommended that trusts meet with the PHA to agree the way forward in relation to ongoing quality improvement in the reduction of MRSA and CDI. (Regional) 2. It is recommended that the staffing complement within the IPC team is reviewed to ensure a proactive preventative approach is taken to the management of infection. 3. It is recommended that IPC link nurses have protected time to carry out their role. Senior members of the trust met with Dr Geoghegan on the 8 June to discuss the trust peer group comparison data and strategies to reduce out HCAI numbers. A reduction target for those CDIs occurring >48 hours was set at a 30 per cent reduction from the previous year. The trust works closely with PHA colleagues in the ongoing monitoring and development of priorities in relation to HCAI reduction plans. A recent IPT was submitted by the trust to the HSC Board. Unfortunately the funding allocation, which was very welcome, did not fully meet the needs of the trust as outlined in our IPT. There are 22 augmented care areas in the BHSCT. This has been discussed at the trusts HCAI Improvement Team meetings and is in place. The trust has recruited approximately 300 staff nurses who will be starting in September. With normative staffing the Ward Sister/Charge Nurse will have a supervisory role and patient safety and quality is the key focus of their nursing accountability framework. Meeting held on the 08/06/15 December 2015 December

24 Reference number Recommendations Criterion 5: Environmental Cleanliness 4. It is recommended that a member of the IPC team is available to attend managerial audits Action required Ward staff take a lead in this and IPCNs support this process as and when resources allow. Date for completion/ timescale March It is recommended that the trust establishes patient representation at key IPC meetings and monitoring programmes Patient representation will be sought for key meetings. January It is recommended that environmental cleanliness and hand hygiene audit results are clearly displayed for staff, patients and visitors to view. Criterion 8: Admission, Discharge and Transfer 7. It is recommended that the IPC Admission/ Transfer Risk Assessment form be reviewed. A robust system should be in place to ensure that staff are instructed when to use the form and the need to either retain a copy of the form or to record that the form has been completed. (Regional) This will be taken forward by the HCAII team. New display boards are on trial. The BHSCT had issued instruction to all staff on how to use these forms and this is working relatively well. Some other trusts are reporting that this is not working for them therefore the Regional Lead Nurse Forum will look again at this form/system. September 2015 January

25 Reference number Recommendations 8. It is recommended that the trust, with the PHA, further develop the use of the ECR to capture patients infection status. The ECR system should integrate with current IT systems, or where necessary one regional IT system, to capture all relevant patient information. (Regional) 9. It is recommended the trust liaise with the PHA to improve antimicrobial stewardship and prescribing in Primary healthcare settings. (Regional) Action required The PHA have taken this forward with the BSO and the Regional Microbiology group and the possibility that the laboratory system can relay alert organism information to ECR appears to be achievable. Consultation with GPs is on-going. The issue of antimicrobial stewardship and prescribing in primary healthcare settings has been raised with the PHA at trust meetings and at the PHA Regional HCAI Forum. It is believed that the PHA are taking this forward. Date for completion/ timescale PHA PHA 25

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