Healthcare Associated Infection rates in the CHP show no unusual activity. DATIX is now being used in CHP Hospital sites and by Community Nurses.

Transcription

1 PAPER 6 LOTHIAN HEALTH BOARD Edinburgh Community Health Partnership Sub Committee Meeting 11 th December 8 Clinical Director CLINICAL REPORT 1 Purpose of the Report The purpose of this report is to update the Sub Committee of clinical developments within the CHP and to update it on clinical governance issues that either arise within the CHP area or, if they arise elsewhere, could be of interest to the CHP. It is also to update the CHP Sub Committee on clinical governance activity and the progress made in the Edinburgh CHP Quality Improvement Team and its Quality Improvement Programme. SUMMARY There have been critical incidents in the CHP. Both have now been investigated and reports have been completed. These will now be considered by the Healthcare Governance and Risk Management Committee of the Health Board. Healthcare Associated Infection rates in the CHP show no unusual activity. DATIX is now being used in CHP Hospital sites and by Community Nurses. The Primary & Community Services Healthcare Governance and Risk Management Operational Group has been reconstituted and the CHP QIT agenda will be remodelled to better reflect that of this group. This should allow for easier governance arrangements. Recommendations The Edinburgh CHP Committee is invited to:-.1 Note that there have been critical incidents in the CHP involving patient documentation and that both of these have been investigated.

2 . Note that both reports will be taken first to the Healthcare Governance and Risk Management Committee of Lothian Health Board. Following consideration by this committee, any recommendations will then come back to the CHP for action..3 Note that there is no abnormal activity in Healthcare Associated Infection (HAI) rates in the CHP..4 Note that DATIX is now being used in all CHP Hospital sites and by Community Nurses..5 Agree to the Clinical Director bringing a future DATIX report (as used by the QIT) to the committee for information..6 Note that the Primary & Community Services Healthcare Governance and Risk Management Operational Group (P&CSHG&RMOG) has been reconstituted..7 Agree that the Clinical Director brings the minutes of the new group to this committee for information and that important points are highlighted. 3 Critical Incidents 3.1 Family in Need (FIN) record A FIN record has disappeared whilst in transit between health service sites in the west of Edinburgh A Critical Incident review group, chaired by the Clinical Director, was established to investigate the incident This group commissioned a Root Cause Analysis (RCA), chaired by Val Baker A report on the incident is now available and will be taken, with recommendations, via the Director of Public Health to the Healthcare Governance and Risk Management Committee (HG&RM) of Lothian Health Board Once the HG&RM committee have agreed the recommendations, the report will come back to the CHP and other operational delivery units in the Health Board for action The report will also be taken through other groups within the CHP to enable full discussion of the findings. 3. Initial Referral Document (IRD) 3..1 A Child Protection IRD was found in the Leith area of Edinburgh. 3.. A Critical Incident review group, chaired by the Clinical Director, was established to investigate the incident.

3 3..3 This group commissioned a Root Cause Analysis (RCA), again chaired by Val Baker A report on the incident is now available and will be taken, with recommendations, via the Director of Public Health to the Healthcare Governance and Risk Management Committee (HG&RM) of Lothian Health Board Once the HG&RM committee have agreed the recommendations, the report will come back to the CHP and other operational delivery units in the Health Board for action The report will also be taken through other groups within the CHP to enable full discussion of the findings. 3.3 Further action taken by the CHP in relation to these incidents will be reported to the CHP Sub Committee in either the Clinical Report or General Manager s Report. 4. HAI 4.1 At the time of writing this report there are no abnormal reports in the incidence of recorded HAI rates in the CHP. 4. A copy of the HAI report for the quality improvement team is enclosed as an appendix (Appendix 1). 5. DATIX 5.1 DATIX is an intranet web based searchable database used to store medication incidents, critical incidents and complaints. 5. Since the beginning of November 8 all CHP hospital sites and community nurses are now using DATIX. 5.3 The NHS Lothian Clinical Governance Support Team are looking to pilot DATIX in several General Practice Surgeries. 5.4 Incidents are entered by members of staff on a web based form. 5.5 A nominated manager, usually the direct line manager, signs off each incident. They would consider whether any immediate action requires to be taken. 5.6 Once signed off the report is available for analysis. 5.7 The QIT has been shown the first CHP report. This has been considered and recommendations have been made to improve the incident analyses. 3

4 5.8 The QIT Administrator will further alter the analysis templates and discuss these with the Clinical Director and Chief Nurse. These will then be presented to the QIT and QIT Core Group. 5.9 This committee will see the minutes of the QIT where the DATIX reports are discussed. 5. A future DATIX report (as taken to the QIT) could be brought to this committee in the future for information. 6. Primary & Community Services Healthcare Governance and Risk Management Operational Group (P&CSHG&RMOG) 6.1 The P&CSHG&RMOG has been reconstituted and is now co-chaired by the Clinical Director of West Lothian Community Health and Care Partnership and the NHS Lothian Associate Nurse Director. 6. There is a desire to standardise reporting to this committee to make identification of themes for action and overall governance easier. 6.3 The co-chairs of this group have met with the other 3 CHP Clinical Directors (at the CHP CD Forum) who have agreed to change the agenda topics of their QITs to reflect the agenda of the P&CSHG&RMOG. 6.4 This should not have any negative impact on the capture of any local variation in quality issues and each QIT will still have the opportunity to capture these. 6.5 The dates of the P&CSHG&RMOP have been altered after negotiation to allow all 4 Clinical Directors to attend. Each CD has agreed to send a deputy if on annual leave. 6.6 We have had the minutes of this group brought to this committee for information in the past. The Clinical Director recommends that we continue to do this and that he highlights any important points as appropriate. 7 Resource Implications 7.1 There are no direct additional costs associated with the topics in this paper. Any actions taken as a result of analysis of various incident and any subsequent recommendations may result in additional costs. Dr Ian McKay Clinical Director 5 th December 8 4

5 Appendix 1 LOTHIAN HEALTH BOARD Edinburgh CHP Quality Improvement Team 8 th November 8 Dr Ian McKay Clinical Director HEALTHCARE ASSOCIATED INFECTION 1 Purpose of the Report 1.1 The purpose of this report is to update the Quality Improvement Team (QIT) on the current levels and trends of Healthcare Associated Infection (HAI) and any remedial action required as a result of deviations from normal background levels. Recommendations The QIT is invited to:.1 Note the current levels and trends of HAI 3 Background 3.1 HAI is a major cause or morbidity and mortality for patients especially those on hospital sites. 3. It is generally accepted that HAI can be minimised and indeed eradicated if simple hygiene measures and prudent antimicrobial prescribing policies are adhered to. 3.3 In addition NHS Scotland has set a HEAT target (T5) to reduce MRSA bacteraemia by 3% by. 3.4 The CHP routinely monitors background HAI levels in both its hospital and community sites. It works closely with the NHS Lothian infection control team to minimise the risk of HAI and to implement policies, procedures and guidelines. 3.5 NHS Scotland and NHS Lothian routinely monitor levels of MRSA bacteraemia and Clostridium difficile isolates. These levels are reported locally and nationally and can be benchmarked against other health board areas and internally between operating divisions and CHPs.

6 4 Edinburgh CHP HAI levels 4.1 MRSA Bacteraemia NHS Lothian MRSA rates NHS Lothian MRSA Rates 6.% 55.% 5.% 4.% 3.% 3.%.%.% 3.%.%.7%.7% 1.3%.6% 4.%.7%.% CHP Managed Site 7. RVH. Liberton 8. SJH 3. Location not given 9. St Columbus Hospice 4. RHSC.WGH 5. RIE 6. Roodlands 4.1. MRSA Bacteraemia trends comparing RIE and Edinburgh CHP 1 RIE / Edinburgh CHP MRSA Episodes ECHP RIE Oct- 7 Nov- 7 Dec- 7 Jan- 8 Feb- 8 Mar- 8 Apr- 8 May- 8 Jun- 8 Jul-8 Aug- 8 Sep- 8 Oct- 8

7 4.1.3 Edinburgh CHP MRSA Bacteraemias MRSA Episodes CHP Managed Sites AAH - East Pavilion A AAH - Mears Ward AAH - East Pavilion B 4. Clostridium difficile (c. diff) 4..1 NHS Lothian C. diff rates NHS Lothian C diff Episodes No. of Cases EDINBURGH CHP MANAGED SITES 11 TIPPETHILL HOSPITAL EDINBURGH CHP GENERAL PRACTICES 1 - WGH 3 - EAST LOTHIAN GENERAL PRACTICES 13 - HERMANDFLAT 4 MID LOTHIAN GENERAL PRACTICES 14 - LIBERTON 5 WEST LOTHIAN GENERAL PRACTICES 15 LOANHEAD HOSPITAL 6 RIE 16 LOCATION NOT GIVEN 7 ROODLANDS 17 - REH 8 RVH 18 - RHSC 9 St JOHNS 19 - EDENHALL - HOSPICES 3

8 4.. RIE and ECHP C. diff Rates 6 RIE / Edinburgh CHP (inc GP Practices) C diff Episodes Oct- 7 Nov- 7 Dec- 7 Jan- 8 Feb- 8 Mar- 8 Apr- 8 May- 8 Jun- 8 Jul-8 Aug- 8 Sep- 8 Oct- 8 ECHP RIE 4..3 C.diff episodes in ECHP Managed Sites Cdiff Episodes CHP Managed Hospital Site 5 AAH Sites Corstorphine Hospital Ellens Glen House Findlay House Ferryfield House Liberton - Lanfine 4

9 4..4 C diff Episodes across Edinburgh and Mid, East and West Lothian managed sites. C diff Episodes CH(C)P Managed Sites EL CHP Managed Site ECHP Managed Sites Mid Lothian Managed Sites West Lothian Managed Sites 4..5 C. diff Episodes recorded in ECHP General Practices C diff Episodes ECHP North East North West South Central South East South West 5

10 4..6 C. diff trends across ECHP General Practices C. diff Episodes LHP General Practice Oct-7 Nov-7 5 Non MRSA / C.diff HAI issues Dec-7 Jan-8 Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 SE SW SC NE NW Edinburgh 5.1 The infection control report covering the Edinburgh CHP sites reports no abnormal variance in the levels of isolation of other organisms. Actions required 6.1 As levels are consistent with previous surveillance periods and are not unusually high, no immediate remedial action is required. 7 Resource Implications 7.1 There is no resource implications associated with this report. Jennifer Evans QI Administrator 4 th November 8 6