The Scottish Government

EMERGENCY (NINTH) MEETING OF THE HEALTHCARE ASSOCIATED INFECTION (HAI) TASK FORCE, HELD AT 10.00AM ON FRIDAY 4 JULY 2008, IN THE PERTH SUITE, CARLTON HIGHLAND HOTEL, EDINBURGH

Present:

Scott ish Government Health Directorates

Mr Paul Martin, Chief Nursing Officer (Chair)

Mr Colin Brown, Branch Head, Patients & Quality Division

Dr Peter Christie, Senior Medical Officer

Mrs Carol Fraser, Nursing Adviser HAI

Dr Malcolm McWhirter, Senior Medical Officer (deputising for Dr Harry Burns)

Mrs Linda Middleton, HAI Team

Dr Mini Mishra, Senior Medical Officer (Primary Care), Scottish Government Health

Directorate

Mr Callum Percy, HAI Policy Lead

Miss Margie Taylor, Chief Dental Officer

NHSScotland and other representatives

Mr David Bedwell, Assistant Director, Health Facilities Scotland

Ms Hazel Borland, Head of Clinical Governance and Patient Safety, NHS Quality

Improvement Scotland

Mrs Susan Brimelow, Director of Healthcare Regulation, Care Commission

Dr Mary Hanson, Microbiologist, Joint Chair Scottish Microbiology Forum

Mrs Margaret Brown, Project Leader HAI, NHS Education for Scotland, (deputising for

Mrs Liz Gillies)

Mr Paul Kingsmore, Director, Health Facilities Scotland and Acting Director

Health Protection Scotland

Mr Joseph Lynch, Regional Organiser, UNISON (deputising for Mrs Bridget Hunter)

Dr Bob Masterton, Medical Director, NHS Ayrshire and Arran

Mrs A MacKenzie, Infection Control Adviser, Care Commission

Mr John McMeekin, Public Involvement Representative and PICT member

Dr Jacqui Reilly, Consultant Nurse Epidemiologist/Head of Group, Health Protection

Scotland

Dr Charles Saunders, Scottish Joint Consultants Committee

Mrs Gillian Stevenson, Nurse Consultant (Healthcare Associated Infection), Infection

Prevention Society (Co-ordinator Scottish Branch)

Ms Jannette Wheeler, Scottish Branch Chair, Association of Domestic Services Management

Mr Tony Wigram, Health and Safety Manager , Scottish Ambulance Service

Mr Paul Wilson, Executive Director for AHPs, Nursing & Midwifery, NHS Lanarkshire

Guest Speaker

Dr Anne Eastaway, Consultant Microbiologist, Health Protection Scotland

The following apologies were noted:

Dr Harry Burns, Chief Medical Officer (Deputy Chair), Scottish Government Health

Directorate (Dr Malcolm McWhirter Deputising)

Mr Robin Creelman, Chair of HAI Task Force Public Involvement Communications Team

Mrs Liz Gillies, Director of HAI Initiative, NHS Education for Scotland (Mrs Margaret

Brown deputising)

Mr John Glennie, Chief Executive, NHS Borders

Mr Robert Howe, Head of Environmental Services, South Lanarkshire Council

Mrs Bridget Hunter, Scottish Partnership Forum (Mr Joseph Lynch deputising)

Mrs Heather Kelman, General Manager, Community Health Partnership, NHS Grampian

Mrs Maggie McCowan, Chair, Infection Control Managers' Network

Ms Jane Murkin, Scottish Patient Safety Programme

Ms Lorna Renwick, NHS Programme Manager, NHS Health Scotland

Dr Eugene Waclawski, Director of Occupational Health, NHS Greater Glasgow and Clyde

1. Welcome and Apologies

Paul Martin welcomed everyone to the meeting and noted apologies as above.

2. Purpose of the Meeting

2.1 Paul Martin advised members that this meeting had been arranged in response to the actions that have resulted from the Clostridium difficile (C.diff) cases at the Vale of Leven Hospital and announcement of an independent review.

2.2 The Cabinet Secretary for Health and Wellbeing announced at the Scottish Parliament on 18 June 2008 that an independent review would be held to examine why local surveillance systems failed to pick up on the deaths and did not alert staff to the number and pattern of cases that were emerging.

2.3 The review is being led by Professor Cairns Smith, Professor of Public Health at Aberdeen University. He will be joined by Professor Mary Henry, Nurse Director of NHS National Services Scotland and Dr Gabby Phillips, a Consultant Medical Microbiologist at NHS Tayside. The team have been asked to provide a report to the Cabinet Secretary by 31 July 2008. Their remit is to examine:

• all of the circumstances surrounding the C.diff cases at the Vale of Leven;
• the adequacy of the surveillance systems and infection prevention and control measures that were in place there;
• the adequacy of facilities, procedures and systems now in place
• what notifications were given by it to the Greater Glasgow & Clyde (GG&C) infection prevention and control committee and Health Protection Scotland; and
• what procedures were followed for informing the Scottish Government of what action has been taken or could be taken.

2.4 The review team had been invited to the HAI Task Force meeting, however they were unable to attend as they as they were conducting interviews at the Vale of Leven Hospital.

2.5 The letter issued to NHS Board Chief Executives on 27 June 2008 from Dr Kevin Woods sets out Chief Executives' accountability to ensure that robust procedures for infection prevention and control management are in place and implemented. The importance of antimicrobial prescribing was highlighted and members were advised that a letter providing advice and priorities for improving prescribing will be issued next week. NHS Boards have in particular been requested to carry out a self assessment against the NHS Quality Improvement Scotland HAI Standards and the NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection.

2.6 Paul Martin advised members that he gave a presentation to NHS Chairs at their meeting on 30 June 2008. The Cabinet Secretary, who Chairs this meeting, was robust in her commitment to the HAI agenda. Paul Martin also attended the Nurse Directors' meeting on 27 June where he had reinforced the HAI agenda and that infection prevention and control is everyone's responsibility. We should all be working together to ensure that patient safety is placed first and foremost. He pointed out that there may be a number of far reaching implications for NHS Boards once the review team has published its findings.

2.7 Concerns were raised that although good guidance was available for NHSScotland the tools for implementation were not always available or in place. Members were advised that NHS Boards' performance against the HAI agenda was to be one of the key issues raised at the annual accountability reviews where this should help to identify any shortcomings.

2.8 Paul Martin mentioned a Department of Health document 'Board to Ward' which provided comprehensive details on roles within Boards. We aim to review this document to assess if it should be adapted for use as guidance in NHSScotland.

Action: HAI Task Force Secretariat to review DoH document.

2.9 Members were assured that any guidance on C.diff would be adapted for use in the community and primary care settings.

3. Presentation: National CDAD Surveillance

3.1 Dr Anne Eastaway gave an informative presentation. A copy of the presentation will be issued along with the minutes of the meeting.

3.2 The following points were raised in discussion:

3.2.1 Education

• The requirement of antimicrobial prescribing education.
• The need for staff to participate in education and training including education delivered at ward level and education of junior doctors and other presentations.

3.2.2 Information, Advice and Support

• C.diff leaflet available on Health Protection Scotland website.
• Health Protection Scotland are planning a HAI event for NHS boards in January 2009. It was hoped to have one sooner, however this has not been achievable.
• Provision of support and advice on the prevention and control of infection to independent healthcare providers and local authorities is fragmented. It is currently in certain areas supplied by Health Protection Teams. Although all guidance regarding produced by the HAI Task Force is freely available.
• There is a need for Infection Control Teams and Infection Control Managers to be more visible within healthcare settings.

3.2.3 Laboratory reporting

• Health Protection Scotland are further developing the ECOSS electronic laboratory reporting system. This includes the identification of 20 alert organisms for HAI and Public Health. All Boards should have test reporting through ECOSS by October.
• Where patients have been transferred to another healthcare setting or discharged before a laboratory result is available, Boards must ensure that results "follow the patient" as a matter of priority.

3.2.4 Policies and Procedures

• The safety of patients is paramount and it should be ensured that patients with Clostridium difficile infection are reviewed on a daily basis by ward staff and that advice is sought from microbiologists and Infection Control Teams if required. Cases of serious illness and clusters of infection should be notified to the microbiologist in order that appropriate clinical action can be taken.
• Clostridium difficile Associated Disease (CDAD) care bundle is being piloted by NHS GG&C and Highland.
• A check list has been developed for Boards to review against to ensure they have addressed requirements for the prevention and control and management of C.diff cases at all levels in the organisation. The check list is currently being reviewed by the Infection Control Managers.
• Any guidance should be sensitive to the community, primary care, Local Authority and Independent Sector.

3.2.5 Reporting Incidents & Outbreaks

• It is not mandatory for Boards to report outbreaks through SHORS (Scottish Hospital Outbreak Reporting System). It was agreed that this should be reviewed by HPS and the Scottish Government HAI Team.

3.2.6 Antimicrobial prescribing

• It was noted that detailed information regarding GP prescribing is better than the information available in hospitals and could be better used to inform understanding.

3.2.7 Patient care

• The fragmentation of care where patients and clinical staff move frequently was highlighted as a real challenge.

Action: Jacqui Reilly and Carol Fraser to meet to discuss SHORS.

3.3 At present not all NHS Boards transfer surveillance data electronically to Health Protection Scotland. Some Boards still do this by sending hardcopies of reports. Anne Eastaway advised members that a project is underway for the development of web based laboratory reporting and it is hoped that test reporting will be available by October of this year and episode reporting by October 2009. Work is currently underway to try to identify duplication of tests so that in future the actual number of cases should be known.

4. Paper HAITF(2008)7

Review Team Role and Remit, NHS Boards look back surveillance exercise, Discussion on Delivery Plan and Actions Underway

4.1 Callum Percy led the discussion on this paper and advised that the Review Team met for the first time on 26 June and is currently developing a time line of actions. Once this has been finalised a copy will be issued to HAI Task Force members.

Action: HAI Task Force Secretariat to send a copy of the Review Team timeline to members.

4.2 Paul Martin informed members that the Cabinet Secretary was keen to issue guidance on NHS dress code as soon as possible. Carol Fraser advised members that a meeting was scheduled for today to discuss the interim national dress code. Charles Saunders commented that he did not consider the Department of Health guidance on dress code was evidence based. Jacqui Reilly agreed that there was a lack of evidence. However good practice should be followed in the absence of evidence and the Department of Health guidance reflected this. Members agreed. It is anticipated that an interim dress code policy will be issued to NHSScotland shortly and that a NHSScotland uniform policy will be issued later this year.

4.3 Health Protection Scotland has been asked to develop guidance on C.diff. They have reviewed the Department of Health guidance (which has subsequently been withdrawn for a revision) and the European guidance. This guidance will be taken into account during the development of the Scottish guidance, due for consultation by 3 September. The next step will be to further develop the guidance to encompass primary care and the community including Local Authorities and Care Homes.

Action: Health Protection Scotland to develop C.diff guidance by September 2008

4.4 Paul Martin informed members that the issue regarding guidance given to relatives when taking home patients' laundry had been raised in a variety of quarters. Carol Fraser advised that the guidance available for the laundering of patients' clothes by relatives is ad hoc. To standardise procedures, Health Protection Scotland has been asked to develop guidance which should be used by all NHS and non-NHS healthcare settings, such as hospitals, care homes, Blood Transfusion Service, hospices and the State Hospital.

Action: Health Protection Scotland to review existing model policies and develop guidance on laundering of patients' clothes by relatives.

4.5 The issue of the lack of single rooms was raised and the fact that there did not appear to be a standard approach to setting up and managing a cohort care area. Definitions and practices vary across NHSScotland. It was agreed that standard guidance should be developed.

Action: Health Protection Scotland to develop guidance on setting up and management of cohort care areas.

4.6 The issue of bed occupancy and bed availability was raised along with the appropriateness of moving and boarding of patients. It was agreed that a strategic review of this issue was required. It was agreed that boarding of patients should be based on patients' clinical needs and risk management.

Action: HAI Task Force Secretariat to consider this area.

4.7 Members discussed the need for standardised treatment pathways/algorithms for the management of patients with Clostridium difficile associated disease (CDAD). It was agreed that the Scottish Antimicrobial Prescribing Group (SPAG) in liaison with Health Protection Scotland should develop algorithms for CDAD. Paul Martin informed members that funding to support the position of an Antimicrobial Pharmacist for each Board was being provided.

4.8 Members were advised that the HAI Task Force Secretariat would be meeting with NHS Education for Scotland to review the availability and topic areas of current education and training packages. Margaret Brown advised that an education and training package for antimicrobial prescribing was available online but that it would require further development to include General Practitioners and Dentists. She also informed members that 2142 'G' grade nurses had completed the Cleanliness Champions Programme and that all Boards had met their target.

Action: NHS Education for Scotland to meet with Scottish Government HAI Task Force Secretariat to discuss education and training, including availability, topic areas and gaps.

4.9 Peter Christie advised members that a Chief Executive Letter (CEL) would be issued early next week covering three key areas (i) The establishment of antimicrobial management teams to cover primary and secondary care prescribing activities; (ii) Implementation and compliance monitoring of local antimicrobial policies and (iii) Supportive funding provided to each NHS Board for the appointment of an antimicrobial pharmacist.

4.10 As already mentioned at paragraph 2.6 Paul Martin attended the Chairs meeting where it was agreed that we need to identify "MUST DO" actions for NHS Boards. Paul Martin asked members to make suggestion for the top five or six actions for notification to NHSScotland.

The following suggestions were made:

• Training and education - we must ensure that staff are able to take up training opportunities.
• Physical environment including the provision of isolation and hand washing facilities.
• Hand gels must not be used as substitution for hand washing .
• Transfer and discharge of patients - we must ensure robust recording and communication pathways to ensure appropriate treatment is continued.
• Patient movement - we must have better communication between Infection Control Teams, Management and Clinicians.
• Governance - HAI must be on the agenda at operational and Board level.
• Template checklist of questions for executive and non-executive members of Boards. This item to be added to the agenda for the NHS Quality Improvement Scotland Patient Safety seminar on 21 and 22 August 2008.
• Information for the public regarding their roles and responsibilities.
• Review available public information in relation to the prevention and control of infection with NHS Education for Scotland, Health Protection Scotland and Health Facilities Scotland.
• NHS Boards and Patient Safety Agenda - the challenge of implementing care bundles more rapidly.
• Hand and respiratory hygiene - Health Protection Scotland will ensure current model policies do take account of cough etiquette, etc, and will consider whether anything further is required and HAI Task Force will ensure hand hygiene campaign includes respiratory hygiene for infection prevention and control.
• Training on surveillance and basic epidemiology for local clinical and managerial staff.

Action: NHS Quality Improvement Scotland to include checklist template for NHS Board executive and non-executive members on the agenda for the Patient Safety seminar on 21 and 22 August 2008.

Action: HAI Task Force Secretariat to review available public information with NHS Education for Scotland, Health Protection Scotland and Health Facilities Scotland.

4.11 Bob Masterton tabled a paper on issues surrounding the completion of death certificates. He pointed out that approximately one third to one half of C.diff notifications on death certificates may be wrong. . The question of how to improve the death certificate process was raised. It was suggested that a root cause analysis review of C.diff deaths would provide a more accurate number of cases. It was agreed that we should be concentrating on prevention and control of infection.

4.12 Funding is to be provided for the process scoping and roll out of ECOSS. It should be made clear that local surveillance is covered Board wide and not just hospital based.

Action: HAI Task Force to allocate funding for the process scoping and role out of ECOSS. HPS/SGHD to develop a framework for local surveillance.

Action: Health Protection Scotland to develop a framework for local surveillance.

4.13 In summary the top five areas cover hand hygiene, antimicrobial prescribing, environment, cleaning and communications and surveillance.

5. Key Challenges for NHS Boards

Hand Hygiene, Antibiotics, Cleaning, Diagnosis/Management and Local Surveillance

5.1 The issue of the conflicting messages between the use of alcohol gel and washing of hands was raised. Health Protection Scotland will review and advise in due course.

Action: Health Protection Scotland to review Hand Hygiene guidance and provide the HAI Task Force with a paper on the use of hand gel.

5.2 An independent audit of the review for the cleaning specification is due for publication in September. Further discussion on the technical specification is required.

Action: Paul Kingsmore to discuss technical specification with Health Protection Scotland and ensure all Health Facilities Scotland work is aligned to model policies for infection prevention and control.

5.3 Guidance on the Management of Incidents and Outbreaks of Healthcare Associated Infection is due for issue within the next few weeks.

Action: HAI Task Force to issue guidance on Management of Incidents and Outbreaks of Healthcare Associated Infections.

5.4 Paul Martin explained the sensitivities around communication protocol and has requested through professional leads that NHS Boards provide detailed daily updates on outbreaks for the foreseeable future.

6. AOCB

The issue was raised that Northern Ireland had conducted an independent review of C.diff and that the Health and Safety Executive had been included. It was suggested that the Health and Safety Executive was not linked into the work of the Healthcare Associated Infection. Peter Christie advised members that the Health and Safety Executive are aware of our Healthcare Associated Delivery Plan and are in fact attending the HAI Stakeholder meeting due to be held on Tuesday 8 July. The Health and Safety Executive also meet with NHS Quality Improvement Scotland. Jacqui Reilly noted that most guidance for facilities in terms of best practice for infection prevention and control was about new builds (HAI Scribe) and there was a need to focus on the fabric of existing buildings. She also noted that the Chief Medical Officer (CMO) priorities for health protection over the next three years included HAI and as such there was an opportunity to maximise the potential for success through promoting the joint working of Infection Control Teams and Public Health/Health Protection Teams.

7. Date of Next Meeting/Scheduled Meeting

Paul Martin indicated to members that there may be the need for a further emergency meeting in August. The next meeting will take place on Wednesday 3 September 2008 from 10.00-13.00 in Conference Room 3, Victoria Quay, Leith, Edinburgh.

HAI Task Force Secretariat

July 2008