patient safety - northern lincolnshire and goole hospitals ... · patient had diarrhoea prior to...

NLG(16)047

DATE OF MEETING 26th

January 2016

REPORT FOR Trust Board of Directors – Public

REPORT FROM Infection Prevention & Control

CONTACT OFFICER Viv Duncanson / Maurice Madeo

SUBJECT C. difficile Action Plan

BACKGROUND DOCUMENT (IF ANY) N/A

REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Infection Prevention & Control Committee , 18th

January 2016

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)

N/A

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

N/A

IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?

N/A

ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?

N/A

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?

N/A

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?

N/A

THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED

N/A

ACTION REQUIRED BY THE BOARD For information

of 23 H:\Governance & Quality Improvement\Infection Control\Vivs DPOW G\Action Plans (current)\2015 - 16\C diff

TRUST Clostridium difficile RCA REVIEW ACTION PLAN 2015/16

Section 1 : Actions brought forward from Trust wide and Site specific C. difficile Action Plans 2014/ 2015 Section 2 : Actions brought forward from 2015/16 Site specific C. difficile Action Groups / CQUIN/ CEO

Challenge Section 3: Actions identified following DIPC RCA reviews

Author: Viv Duncanson


Reference Action Lead Timescale Verification ACTION STATUS

Ward C6 DPOW

Date of specimen 29/09/2013

Date of DIPC review 18/11/2013

HAI

Deemed : Not preventable

15.01.01 Previously 14.01.05

Develop a process for formal removal of pen allergy entries when established there is no true allergy.

Andy Karvot End of Jan 2014 Deadline end of

April 2014 New deadline end

April 2015 New deadline Dec

2015

Formal process in place April 2015: NICE CG183 gap analysis done and analysed by AK and Jeremy Daws (JD) Trust Drug Allergy Protocol to be written by AK, decision on availability of appropriate lab tests to be discussed by JD with Prof. Sewell and Ian Barlow, AK to check that Trust documentation meets recording standards for drug allergy and adverse drug reactions as per CG183 and JD & Katheryn Helley to look into will to commission a locally available drug allergy testing service. Policy will include removal of pen allergy label when appropriate. AK to provide update to IPCC by October meeting. Nov 15: Ongoing. Kate Woodrow taking over NICE CG183 which is the management of drug allergies. This will be included as part of this review and this action will be taken over by Medicine and therapeutics committee

Section 1 : Actions brought forward from Trust wide and Site specific C. difficile action plans 2014/ 2015

TRUST Clostridium difficile RCA REVIEW ACTION PLAN 2015/16: as at 01/04/15



Ward : Amethyst


15.02.01 (Previously 14.15.01)

Patient had diarrhoea prior to admission:

Missed opportunities for sample taking and isolation of the patient by AMU and Stroke Unit leading to case being classified as hospital acquired.

Ivan Bernal-Torne

Kelly McLean

End of June 2015

Verified by ward sister / charge nurse

May 2015: Work books distributed and completed books being received by Ward Sister / Charge nurse June 2015: Completed

Date of DIPC review 29/1/2015 AMU staff and Stroke Unit staff to complete

HAI: the C. difficile booklet and review top tips for C.difficile poster

Deemed :

15.02.02 (Previously 14.15.02)

Noted late inter-hospital transfers (22.00 hrs and 22.50 hours) Patient is 95 ?appropriate

Discussion with Ops manager to request review of policy in relation to a hierarchical approach to identifying patients fit for transfer and patients who should not be transferred.

VD to liaise with Simon Buckley

End of April 2015 Review of policy Liaison with S Buckley. Factors identified to be included in policy. SB will discuss with Ops team.

April 2015: SB has agreed with Paul KW and has attended the ward managers meeting to discuss the shared responsibility. All have and agree a more

robust identification process.

Not preventable as pt had symptoms prior to admission

TION STATUS

Reference Action Lead Time scale Verification AC

Ward : Goole 3



HAI:

Deemed : preventable

Practice issues noted on CDU 15.03.01 Susan Samways End of

(Previously Green decontamination tape not used on Di Hughes

14.16.01) commodes Kay Newton Delay in commencing the C.diff pathway

Staff to be reminded. Of above practice issues

IPCN to liaise with Matrons to ensure spot checks on commode decontamination are carried out.

Completed April 2015 Audit data evidencing

green tape being used correctly



Ward : B4 DPOW


Date of DIPC review Tbc

HAI:


15.04.01 (Previously 14.17.01)

Improve compliance with trust C. diff policy. Sarah Stinson End of Jan 2015 End of March 2015 Local action plan produced including : All staff have completed the C.diff work book and included in staff news latter and staff meeting. 1:1 sessions held with staff involved in this case.

15.04.02

Lack of air mattresses noted .Review provision of air mattresses

New mattresses are being trialled. This issue escalated to the pressure ulcer group for further action.

15.04.03

Following the C. diff diagnosis the patient received a long course of Cipro, (compounded by the completion of the electronic discharge system). To be discussed and reviewed by the safety and quality days for each group and discuss with the Medical Director.

Andy Karvot End of May 2015 Feedback to the C. diff action groups.

July 2015: AK has emailed Mr Lawrence Roberts, Medical Director, with message he has requested. Incorporated into Medical Directors weekly News Letter to say that: “ All prescribers should take care to take account of any inpatient antibiotic course received by the patient when prescribing antibiotics on discharge, so that longer than optimum course-lengths are not inadvertently received by patients

Reference Action Le ad Time scale Verification ACTION STATUS

To investigat Ward C6 15.05.01 endoscopy fo

(Previously procedures Date of specimen 14.20.01) 09/12/2014


HAI:


e fast track access to

r complex in patients requiring PK

W End of

April 2015 Endoscopy Unit have confirmed that arrangements are in place do the patient first thing in the morning to avoid disruption to the scheduled list. These arrangements will be reviewed and picked up as part of the GI Bleed Service review currently underway.



Ward : 17 SGH


15.06.01 (Previously 14.25.01)

Mr Roberts to discuss cephalosporin prescribing with Primary Care, although this issue was not necessarily related to the C difficile case.

LR End of May 2015 Liaison with P. care

Medical Director now has access to the CCG medical newsletter where key messages will be

posted. Date of DIPC review 13/04/2015

HAI: 15.06.02

All staff on ward 17 have been made of the correct procedure to isolate patients directly when a faeces sample has been obtained and not to wait for the result.

Jo foster

End of April 2015

Signatures from staff once completed

Completed Deemed : Not preventable

15.06.03

All staff on ward have completed the ‘Infection Control’ workbook.

Jo Foster

End of April 2015

Verification by Ward Sister

Completed

15.06.04

Since the incident spot checks have been undertaken on the cleanliness of the commodes by the Chief Nurse, IPCN and Operational matron and no further problems identified.

Susan Samways End of March 2015 Audit data Completed



NIL as at May 2015

CEO Challenge 24/11/2015

CEO 1

CEO 2

In view of rising number of cases a weekly CEO challenge meeting is taking place from August 2015

Convene a task and finish group to review antimicrobial issues as per the Hygiene Code requirements. Issues

Actions form first meeting :

Ensure antimicrobial steering group is fit for purpose . addressing all antimicrobial stewardship issues and keeping the Trust Board informed

Antimicrobial audits; specifically looking at clinical appropriateness for perceived indication, feedback to clinicians

Reporting of antimicrobial susceptibility data Address gaps in education

Continue with monthly meetings until issues resolved

CEO Weekly Action log October 2015: Meetings commenced in August Ongoing action log commenced to address issues as they arise 24/11/2015/. CEO meetings discontinued. Outstanding actions to be added to This action plan and IPCC.

KD / AK Feb 2016 First meeting of task and finish group held 27/11/2015. Meet monthly until issues resolved

CEO 3

Cleanliness reports to be added to IPCC agenda KD / Keith Fowler

Dec 2016 Standing agenda item added to IPCC

IPCC to become sub group of the Board for 6 months and review

KD Dec 2015 Commenced and ongoing first meeting held December

CEO 4

Section 2 : Actions brought forward from 2014/15 Site specific C. difficile Action Groups / CQUIN / Increased Incidence/ CEO Challenge


Reference Action Lead Timescale Verification ACTION STATUS Reference

CEO Challenge 24/11/2015

CEO 5

Determine a process with CSU / CCG’s for requests for removal of cases due to “NO LAPSE IN PRACTICE”

WB / VD Jan 2016 Meeting with CCG’s. Flow chart produced and agreed. Lapse in care reviewed by Quality committee

CEO 6

Upgrade C floor showers Jug Johal Feb 2016

CEO 7

Renew ward 24 flooring Jug Johal

Feb 2016 Completed

CEO 8

Consider the implementation of HPV decontamination

Maurice Madeo

March 2016


Reference Action Lead Tim escale Verification ACTION STATUS

15.07.01 Ward: 24 SGH Marion

Lessons learned: Highlight the issue to Date of specimen the ward Sister re 24-48 hours of no 05/04/2015 antibiotic given during the i/V oral

switch and review the reason why. Date of DIPC review Feedback to all ward 24 staff

03/07/2015

CAI : NLA G issues

Deemed: Awaiting CCG DIPC review

End of August 2015 Hewis and Andy Karvot

Completed. Liaison with the Ward sister who has fed back to ward 24 staff


Ward C6 DPOW 15.08.01 Discuss ?inappropriate transfer of patient

from C6 to a bay in B4

Andrea Webster- Cockrill/

End of July 2015

Review of appropriateness of

Discussed with Simon Buckley. Case reviewed and discussed with site managers

Date of specimen Simon Buckley patient transfer 04/04/2015

Date of DIPC review 15.08.02 Poor documentation of stool chart

Ward staff undergoing the C.difficile work book

Jo Jones / Sarah Stinson

End of August 2015 Completion of work book Completed

2/07/2015

HAI:

Deemed : 15.08.03 Discuss 1:1 with Consultant Dr Sarwar re

antibiotic prescription. Tazocin Px concurrently with Flucloxicillin and Amoxil

Andy Karvot

End of August 2015 Verification by AK that discussion held

AK has liaised with Dr Sarwar who has agreed to review the case.

Preventable

15.08.04 To include on the pilot ward round check lists a reassurance that there are not multiple live prescription sheets.

Lawrence Roberts

Immediate

Inclusion on Px sheet Requested to be included on the ward round check lists

Section 3: Actions identified from RCA reviews



Ward: 28 SGH



HAI:

Deemed : Possibly preventable

15.09.01 Consultant Antimicrobial Pharmacist will discuss this case on a 1:1 basis with the relevant pharmacists / technicians regarding the history of the antimicrobial prescriptions and the review that was undertaken of this case.

Andy Karvot 1:1 Discussion end of August 2015

AK has spoken with ward pharmacist who had reviewed prescription, who had thought that antibiotic chosen was appropriate, despite long course. Discussed intervention with prescribers if repeat courses and longer than usual. Training complete.

15.09.02 Andy Karvot to formulate a programme to work / provide supervision to ward pharmacists regarding antimicrobial review

Andy Karvot Commence immediately

complete by end of March 2016

Programme drawn up: AK to perform 1:1 training with at least 1 pharmacist per site per month October 2015. Training ongoing; scheduled to complete by March 2016.

15.09.03 Andy Karvot is currently working on the new prescription sheet that will include antimicrobial stop dates

Andy Karvot End of August 2015 New date Dec 2015

Final format agreed / ratified by Medicines and Therapeutics Committee. October 2015: Printing tender proof revealed some required modifications. Will be printed in- house by NLAG Reprographics. AK to agree final changes with Philip Johnstone. November 2015. Completed

15.09.04 Relevant ward staff to undergo C.diff training / undertake the C.diff booklet

Michelle Long End of Aug 2015 Completed

15.09.05 Broken soap dispensers to be replaced on ward 28

Susan Samways End of Aug 2015 New date Nov 2015

Requested dispensers from Ecolab. Sept 2015: No dispensers available from Ecolab. Have been put on order as urgent. October Dispensers received

15.09.06 Lawrence Roberts to discuss with Dr Ahmed the requirements of this case with regards Duty of Candour.

Lawrence Roberts End of Aug 2015 Completed

15.09.07 Death certificate:. Mr Roberts identified that more work is required on raising awareness of completion of death certificates correctly

Lawrence Roberts 1:1 discussion with Dr Hanna end of

Aug 2015

Mr Roberts has sent out a Medical Directors bulletin with instructions on filling out death certificates . In addition the subject has been put on the HCC agenda for discussion ref centralising deathe certificates.

15.09.08 As C.diff was reported as 1c on the death certificate – Viv Duncanson will discuss with Wendy Booth to ascertain if this case should be escalated as an SUI

Viv Duncanson Immediate Liaised with colleagues currently who are working out the process

Escalation flo chart produced in conjunction with Wendy Booth



Ward: Stroke Unit 15.10.01 Request that the Stroke Group review the

Jon Wood

End of October 2015

Feedback from Stroke

Tabled at Stroke Group case with regards the interval between

DPOW admission and definitive diagnosis to Group via Jon Wood

determine whether there was undue delay Date of specimen in obtaining an MRI based diagnosis 31/05/2015

All other actions have been completed:

Date of DIPC review 15.10.02

Actions have been taken regarding the mis- labelling if the specimen to prevent reoccurrence. Requires reporting on to the datix database

Jane Stocks

Completed 27/08/15

HAI

Deemed: Not

15.10.03 Education re isolation and stool specimen taking has been completed with all members of staff

Andrea Webster-Cockrill Completed

preventable



Ward: C1K DPOW 15.11.01 Infection Control to be added on to the Ops

Jon Wood

End of Sept 2015

Completed communication template

Date of specimen 15.11.02

Ensure newly appointed Deputy Site Managers to have time scheduled with an IPCN

Simon Buckley/ Ali Wickham

End of November 2015

X1 Deputy site manager has had 1:1 with IPCN 18/06/2015


HAI 15.11.03

Death certification: Medical director to follow up the case with the specific doctor

Lawrence Roberts

End of sept 2015

Completed. MD’s bulleting sent out instructing on correct way of completing death certificates

Deemed: Not preventable

15.11.04 Cleaning of mattresses: there are still some areas where local cleaning of mattresses is taking place. Business case to be reviewed and to raise issue at CEO meeting

Tara Filby End of Sept 2015 Raised at CEO meetings.

Tara Filby has ensured that mattresses are not cleaned at ward level and the facility for sending mattress to an external facility is available

15.11.05

Lab report sensitivity. PC to check that amoxicillin release is always released when Co-amox is released

Peter Cowling

End of Sept 2015

Review by PC revealed that there is no function within the rules that detects whether or not an antibiotic has been released or suppressed.



15.12.1 AK to be asked to lead a revisit of the Ward: DPOW B6



HAI


orthopaedic prophylaxis issue/ antimicrobial policy involving the Orthopaedic consultants, Consultant Microbiologist, and Acute Kidney injury Consultant. LR / AK

End of Nov 2015 Review of policy October 2015: Raised at CEO’s weekly Clostridium difficile Challenge Group by AK. Dr. Cowling felt that issue too complex to make a decision at that group. Mr. Roberts will retain on “to do” list and will raise when Royal Orthopaedic Society guidance is updated. Nov 2015: Ongoing Further discussion at Pathlinks antimicrobials group meeting 17/11/2015 Meetings scheduled to meet with Ortho Clinical Lead to agree way forward Dec 2015: Meeting cancelled to be rescheduled

15.12.2 Penicillin allergy remains an issue. Noted that it appears on the Trust action plan as an ongoing issue. Medical Director aware

AK See 15.01.01 Review / Update to protocol

October 2015: AK to provide update to Infection Prevention and Control Committee in Nov 2015.

Changes to policy ratified.

15.12.3 Review actions for GDH positive patients Lawrence Roberts/

IPCT

End of September

2015

Review / Update to protocol

October 2015: Flo w chart and actions drafted by IPCT To be ratified at Oct IPCC.

Ratified by Oct IPCC

15.12.4 Review/ assess whether cefuroxime should

be the second line choice for gynae / obs patients

AK/ Microbiologists End of September 2015

New date: end November 2015

Review / Update to protocol

November 2015: To be considered at Path Links Antimicrobials Guidance Committee meeting. Has been agreed that cefuroxime is correct as second line choice for gynae / obs patients



Ward: SGH 24 15.13.01

Continue to monitor commode cleanliness by completing spot checks

Quality matrons and IPCN’s

Immediate and ongoing

Implemented and ongoing


Date of DIPC review 15.13.02

Improved decision making re antibiotic choice (Tazocin) and improved documentation in support of choices made.

AK and PC

Dec 2015 Decision making on when to use piperacillin /

tazobactam incorporated into the Trust’s Antibiotic Formulary and Prescribing Advice for Adult Patients. Improved documentation in support of choices made. New adult treatment sheet with dedicated antibiotics prescribing sections, released 16/11/2015

6/8/15

HAI

Deemed: Possibly preventable

TION STATUS

Ward: 3 DGH



HAI


Reference

15.14.01

Action Lead Timescale

Ward staff to be reminded that in addition to ward urinalysis, specimens of urine should be taken and sent to the Lab when urine is cloudy / signs of infection

MH and Ward Sister ward 17 at SGH

Immediate

Verification

Confirmation of communication

ACTION STATUS

Completed

Reference Action Lead Timescale Verification AC

Ward: B4 DPOW



HAI


15.15.01 Nil actions identified N/

To be sent for consideration of taking of total cases as no lapse in practice

A N/A N/A

Completed


Reference

Action

Lead

Timescale

Verification

ACTION STATUS

Ward: B4 DPOW 15.16. 01 Full generic MDT required to review the Dr Khan / Kev Taylor End of sept 2015

Best interest meeting held by Dr Naqvi’s team ongoing plan and care for this patient – Dr (C6) Khan / Kev Taylor 4/11/2014

Date of specimen

20/07/2015 15.16.02

Review of patients penicillin allergy status

AK

End of Dec 2015 Completed. Decided patient was not pen allergic

Date of DIPC review

21/09/215 15.16.03

Relook at bed management process with regards to why the patient was out – lied.

PKW

End of Nov 2015 Policy checked: considered robust. Recirculated

to all ward managers

HAI

Deemed: possibly

15.16.04

Review / Feedback documentation issues to medical and nursing staff –

PKW / LR

End of Dec 2015

Completed via medical directors newsletter

preventable

15.16.05

MRSA screening. New policy on a page has been implemented and staff made aware.

JJ

Immediate

Completed

15.16.06

Recognised that there are a number of new staff : IPCN to work on the ward alongside staff to support and train in IPC techniques and policies (specifically MRSA, isolation and C. difficile)

AWC

Commence 1/10 and ongoing for 3

months Review Jan 2016

Completed

15.16.07

Revisit hand over process / process for escalation out of hours (Medical and nursing)

LR & PKW

End of Nov 2015

Completed Conversation has been held with the Groups > Rota has been updated

15.16.08

For patients who are difficult to cannulate, ensure staff are aware of the vascular nurse role Nick Harrison / Maggie Parker

PKW

End of sept 2015

Completed. Included in staff magazine. Extra sessions delivered by IPCN

15.06.09

Ensure staff aware of correct procedure for sending specimen for catheterised patient : Kev Taylor

Kev Taylor

End of Oct 2015

Kirsty Dent Ward Manager has conveyed the message to all C6 staff on an informal basis and will discuss at the ward training day that has been arranged for October



Ward: SSRU SGH 15.17 Ward sister to raise awareness with regards

commencing stool charts for patients with

Tina Drewery

End of October 2015 Completed. Lessons learned raised at team

meeting

Date of specimen diarrhoea / at time of sending specimens.

2/8/15

Date of DIPC review

Ward sister to ensure that staff are aware to document rationale for deviations from isolation policy when thought to be relevant. These deviations should be checked with the IPCN.

Tina Drewery

End of October 2015

Completed /. Lessons learned raised at team meeting

16/10/2015

HAI

Deemed: Not Dr Banerjee to follow up with Dr Qureshi lack of notes in medical records

Dr Banerjee

End of October 2015 Completed

preventable

Ensure feedback re dust is dealt with immediately

Marion Hewis

Immediate Confirmation t received that dust was dealt with

and removed on the day it was noted



Ward: 24 SGH 15.18.01 Feedback given via News flash incident

process (ward communication)

Ward sister Sharon Roberts

End of Oct 2015 Documents used for news flash

Completed

Date of specimen

2/8/15 15.18.02

Ward hand over used to highlight the incident / lessons learned

Ward Sister Sharon Roberts

End of Oct 2015 Ward documents Completed


HAI 15.18.03 PC and TD to review the sample journey –

to identify where it went wrong?

Peter Cowling

End of Dec 2015

Report from PC Mark Cioni Lab manager has reviewed this . Issues identified at the lab end with regards processing the specimen have been corrected

Deemed: not 15.18.04 Communicate to teams that bed spaces / bays must undergo a terminal clean cleaned when potentially and infected patients are moved / transferred

Pete Bowker Tony Dawson

End of Nov 2015

Evidence of communication

Completed preventable

15.18.05

Review terminal cleaning process for the 3x cases on ward 24

Jayne Girdham

Immediate

Facilities records Unable to obtain full assurance that areas had been cleaned to due lack of records. Facilities now keep robust records that are sited on the intranet.

15.18.06

Escalate state of fabric of ward 24 to weekly CEO challenge meeting

Karen Dunderdale Jug Johal

Immediate Improvement in flooring KD has escalated concerns to Director of

Facilities. Ward 24 has been moved to the top of the work schedule.

15.18.07

VD to escalate to NMAF the issue of implementing isolation correctly e.g. cleaning and mop and bucket being available for isolation side rooms.

Viv Duncanson

Dec NMAF NMAF minutes Escalated to Tara Filby for December NMAF

meeting



Ward: 6 Goole (28 SGH)

15.19.01 Consider review of trust antimicrobial policy to reflect age and previous antimicrobial history before giving high risk antimicrobials

PC and AK

End of Jan 2015 Updated policy Warnings on the policy have been clarified.

Document also covers ULH and so could not be amended as full agreement not reached


Date of DIPC review 15.19.02 Ensure the orthopaedic case is subject to a DIPC review

VD

End of Nov 2015 Notes from meeting Review meeting held 17/11/2015 with Mr Bayne.

A DIPC review meeting is being held to review 4 / 5 SSI orthopaedic cases in December. It was agreed that ward 6 / ward 28 followed the antimicrobial policy (but did not take in to account the prolonged prescription of Cipro by the GP and the pervious orthopaedic admission (for a SS Joint infection) . Dr Cowling has asked that the current policy takes in to account the patients age

12/11/2015

HAI

Deemed: Not

preventable


Ward: 22 SGH 15.20.01 Failure to isolate / Failure to identify

appropriate outlier. Debrief ward staff using

Tony Dawson

End of Nov 2015 Staff meeting Completed


a lessons learned approach – action Tony Dawson

Date of DIPC review

15.20.02 Follow up transfer process to ensure that the vacated side room was cleaned when the patient was transferred out

Viv Duncanson

End of Nov 2016 Verification by checking Facilities terminal cleaning records

Facilities could not verify this, but now keep robust records for terminal cleans, which are available on the intranet.

30/10/2015

HAI

Deemed: Not

15.20.03

Request that Ops centre record where complex decisions are required in order that review / lessons learned / support can be given.

Graham Jaques / Simon Buckley

End of Nov 2015 All Ops staff reminded to document rationales

preventable

15.20.04 Mr Roberts to follow up absence of Clinician at DIPC review.

Mr Roberts

Immediate Completed



Ward: 16 SGH 15.21.01 Reminder to ensure that microbiology

results are reviewed in a timely manner as

MR L Roberts

End of Dec 2015

Newsletter Completed via MD’s newsletter


per antimicrobial policy to be included in MD’s newsletter


15.21.02

IPCT to review use of a C. diff predictor / risk score is being used in any other trusts

Dr Cleeve and IPCT

End of Jan 2016 Search for predicator tools carried out and

reviewed. There are no tools in existence that can be transferred directly for use by NLAG. Suggest campaign on raising awareness re C.diff and infection risk factors. To be discussed at next FULL IPCT meeting

HAI

Deemed: possibly preventable

H:\Governance & Quality Imp

of 23


Ward: C5 DPOW



HAI

Deemed:

15.22.01

Delay in isolation (7 days) Matron to try to identify members of staff who were involved in the case ‘interview’ them / consider a file note being recorded

Kevin Taylor

End of October 2015

Confirmation action completed from Matron

Difficulties in identifying individual staff members and so all staff included in the actions. One agency nurse involved in the case will not be employed by the Trust in the future

15.22.02

Poor documentation with nursing records regarding stools and classification: Stool chart commenced for every patient on ward C5, all staff to sign document on entry.

Kevin Taylor

Immediate

Confirmation form Matron

Implemented

15.22.03

Trust document needs updating to accommodate signature.

VD to liaise with Hazel Moore

End of October 2015

Document ratified at NMAF

Completed and ratified 6/11/2015

15.22.03 Education of staff by IPCN regarding recognising Bristol stool chart classification. and when to isolate. Ensure staff have pocket sized aid memoirs for stool specimen collection Ensure posters depicting Bristol stool chart are available Provide extra education

Kevin Taylor and Ward Sister

Jo Jones

End of January 2016

Immediate

Education commenced Credit card sized aid memoirs distributed to all staff Education completed

15.22.04 Investigate reasons and subsequent actions as to why the lab did not ring the ward with the result- PC/ Mark Cioni

Peter Cowling Mark Cioni

End of Nov 2015 Investigation conducted by Marc Cioni. . Phone log not completed by lab staff although member of staff said that they did ring the ward. The need to complete the phone log has been stressed at the lab meeting using this case as an example. Highlighting exactly what impact not phoning the result may have.

15.22.05

Investigate reason for Consultant Microbiologist not being available via telephone when Dr Menon called

Peter Cowling End of Nov 2015 This was period where there was sickness re Consultant Microbiologists leading to a temporary shortage of Consultants. Consultant busy on other calls. Now resolved

15.22.06

Review induction information given to agency staff by the Trust.

Wendy Booth

End of Nov 2015 IPCT have developed top tips for “transient “

staff. Sent to Wendy Booth

15.22.07

Review feasibility of staff ringing the lab to inform them when a C.diff test is require – IPCT

Peter Cowling / IPC

T

End of Dec 2015 This has been considered and has been deemed not possible due to the lab deciding whether or not to perform a C.diff test using a strict protocol, which takes in to account consistency, location , age. clinical details and previous specimen history. As long as the lab is provided with all relevant information a C.diff test will be performed.

15.22.08

rovement\Infection Con

Review the terms ‘frailty and old age’ (as recorded on the death certificate) to see if they are acceptable causes of death. - LR

trol\Vivs DPOW G\Action Plans (current)\2015 - 16\C diff

Lawrence Roberts

End of Dec 2015 Med Director feedback: ‘Frailty’ can be used in

a death certificate and may be the only reason for death given if the patients is over 80 with certain restrictions. Med Director will communicate this to medical staff.



Ward: AMU short stay

15.23.01

Review the catheter journey with regards catheter remaining in situ or removal– L

Linda Barker

End of Jan 2016 Catheter journey reviewed. Well documented in

the patients records the need for the catheter to remain in situ and further reviews.

Date of specimen Barker

17/11/2015

Date of DIPC review

15.23.02

Escalate the case for review to the End Of Life Mortality Review group

LR to Jeremy Dawes

End of Dec 2015 Completed

16/12/2015

HAI 15.23.03 Review process of paper referrals of

inpatients to Endoscopy

Simon Buckley End of Jan 2016

Deemed: Possibly preventable

15.23.05 Prescribers of the Cefalexin and Cefuroxime need to be identified and followed up.

Andy Karvot / Tony Vicca

End of January 2016

TION STATUS

Reference Action Lead Timescale Verification AC

Ward: 24 SGH



HAI

Deemed: possibly preventable

15.24.01 To identify rationale for Ceftriaxone as not

clear according to medical records although Dr Cow

appears to have been approved by covering microbiologist.

ling 14/01

/2016 ICC Discussed with Jnr Dr the rationale for agent and antimicrobial pharmacist. Clarification established. Prescribed as advised by on call Microbiologist (Boston) – considered as a lapse in care case



Ward: Amethyst


Date of DIPC review

HAI

Deemed:

15.25.01

15.25.02


Ward: Amethyst


Date of DIPC review

HAI

Deemed:

15.26.01

15.26.02



Ward: Amethyst


Date of DIPC review

HAI

Deemed:

15.27.01

15.27.02


Ward: 24 SGH


Date of DIPC review

HAI

Deemed:

15.28.01

15.28.02