Minutes of the Infection Prevention Committee held on 29th October ...

Agenda Item No. 12.2
THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST
MINUTES OF INFECTION PREVENTION AND CONTROL COMMITTEE MEETING
HELD ON THURSDAY 29 TH OCTOBER 2009
10.00AM, CONFERENCE ROOM, HOLLYBUSH HOUSE, NEW CROSS HOSPITAL
Present: Mr D Loughton (Chair) (Chief Executive) (DL)
Mr J Vanes (Non-Executive Director) (JV)
Ms C Etches (Director <strong>of</strong> Nursing & Midwifery (CE)
Pr<strong>of</strong>. R Fitzpatrick (Director <strong>of</strong> Pharmacy) (RF)
Ms S Roberts (Hotel Services Manager) (SR)
Ms S Harper (<strong>Infection</strong> <strong>Prevention</strong> Nurse) (SH)
Dr J Odum (Medical Director – Division 2) (JO)
Dr G Martinelli (Consultant – Cardiothoracic) (GM)
In Attendance: Ms J Sharp (Occupational Health Manager) (JS)
Ms G Evans (SHA representative) (GE)
Ms S King (Matron Representative) (SK)
Ms K Bowley (Part) (Matron) (KB)
Apologies: Dr M Cooper (DIPC) (MC)
Mr B G Millar (Medical Director) (BGM)
Ms V Hall (Chief Operating Officer) (VH)
Ms J Taylor (HCAI Programme Lead – SHA) (JT)
Dr A Phillips (Director <strong>of</strong> Public Health – WCPCT) (AP)
2. <strong>Minutes</strong> <strong>of</strong> Meeting <strong>held</strong> on 24 th September 2009
Action
The minutes were accepted as a true record.
3. Matters Arising from <strong>the</strong> <strong>Minutes</strong>
No items from <strong>the</strong> minutes were raised.
4. Occupational Health Update
JS gave details <strong>of</strong> <strong>the</strong> current situation, <strong>the</strong> main points being:
Needlestick Incidents
28 Needlestick incidents June-August 2009. European Hospital and Healthcare
Employers’ Association have signed an agreement on prevention <strong>of</strong> sharps
injuries. A Hotline message has been set up on X6222 to inform staff <strong>of</strong> <strong>the</strong>
procedure to follow in <strong>the</strong> event <strong>of</strong> sustaining a needlestick injury.
DL requested that suggestions from <strong>the</strong> <strong>Committee</strong> on how to reduce <strong>the</strong> number
<strong>of</strong> needlestick injuries by 20% per year be put forward.
ALL
Seasonal Flu Vaccines
OH nurses since 5 October 2009 have visited wards, departments, Grand Rounds,
Senior Managers’ Briefings to administer season flu vaccines. At 21 October
2009, 565 from a total 5383 staff have been vaccinated, although May/June figures
Page 1 <strong>of</strong> 10

Agenda Item No. 12.2
are to be added to <strong>the</strong> statistics. JS expressed concern at <strong>the</strong> low uptake in A&E
and Paediatrics. There had been some complaints from some staff in <strong>the</strong>se areas
<strong>of</strong> adverse reaction to <strong>the</strong> vaccine. DL asked JS to ascertain from midwives what
reactions had been suffered. The overall level <strong>of</strong> uptake was considered
unsatisfactory and DL asked that JS keep him updated daily on <strong>the</strong> situation. The
vaccine programme will continue until December 2009 as necessary. The OH
team will make provision for out <strong>of</strong> hours staff and will attend <strong>the</strong> doctors’ forum on
12 November 209 to administer vaccinations.
DL to meet with Christopher Watkins, Trust Secretary, and JS to decide how best
to communicate <strong>the</strong> importance <strong>of</strong> <strong>the</strong> vaccination.
JS
DL
5. Environmental Report
SR reported:
Deep Cleans:
The programme for 2008/09 concludes at <strong>the</strong> end <strong>of</strong> September 2009.
Outstanding areas are:
High Risk Areas:
Ward D5
Ward C5
Radiology
ESS
In response to a query from DL, SR reported that <strong>the</strong> reason Radiology had not
undergone a deep clean was due to an issue around PFI and concerns about
access to areas where equipment is located. DL said he would take up this matter
personally with Anthony Leese, Head <strong>of</strong> Radiology Services.
DL
The new deep cleaning programme for 2009/10 commences in October 2009 for
very high risk areas.
Technical Audits
Over <strong>the</strong> last nine months an electronic auditing system has been used involving
hand <strong>held</strong> PDAs. Results <strong>of</strong> <strong>the</strong> data collected are available on <strong>the</strong> summary sheet
circulated to <strong>the</strong> group.
There were no ‘red’ areas. The following in-house scores were achieved during
<strong>the</strong> period 31.08.09 – 27.09.09:
Very High Risk Areas: 91% Good (yellow)
High Risk Areas: 98% Excellent (green)
Significant Risk Areas: 94% Good (yellow)
Use <strong>of</strong> Shower Curtains
The Environment Group had reviewed <strong>the</strong> use <strong>of</strong> shower curtains and decided:
- Remove where possible and use door screens to ensure patient dignity.
- New shower curtains to be replaced quarterly as a minimum.
The content <strong>of</strong> <strong>the</strong> report was accepted by <strong>the</strong> <strong>Committee</strong>.
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Agenda Item No. 12.2
6. Divisional Reports
Division 1:
GM reported:
‘Red’ areas on <strong>the</strong> scorecard related to antibiotic prescribing training in Urology,
Ophthalmology, Head & Neck; device-related HABS in Oncology/Haematology and
ICCU. GM felt that <strong>the</strong> scorecard was showing incorrect information and would
speak to Ruth Horton (Service Improvement Department)
The HII1 (Peripheral IV cannula care bundle) also showed non compliance by
Oncology/Haematology. GM reported on discussions with Dr Simon Hester and a
Physio<strong>the</strong>rapist, when it was considered that an RCA type document should be
completed where <strong>the</strong>re is HII non-compliance to assist in discovering if infections
were being transferred from o<strong>the</strong>r areas. GM was keen for this process to <strong>the</strong>n be
shared across <strong>the</strong> Trust in <strong>the</strong> form <strong>of</strong> mandatory training. CE considered <strong>the</strong>
suggestion a good idea in principle and that ANTT training around line insertion was
key and would have a significant effect on all infections.
GM, JO and MC to discuss <strong>the</strong> practicalities and benefits introducing such a system
outside <strong>of</strong> <strong>the</strong> meeting and report back to IPCC at a future date.
GM/JO/MC
The RCA summary relating to 1 x C.Difficile in ICCU was noted.
Areas <strong>of</strong> focus over <strong>the</strong> next month:
• ICCU – new chart devised to be trialled during microbiology round
• ICCU – reusable masks ordered.
• Cardiac – replace fabric covered chairs
• Cardiology Ward – introduce clipping prior to procedure
• Urology – use <strong>of</strong> cleaning tags
• Haematology/Oncology – hand hygiene training
Division 2:
JO reported:
The RCA summaries relating to 4 x C.Difficile (1 x ESS, 2 x D16, 1 x D19 and 1 x
MSSA - NNU) were noted by <strong>the</strong> <strong>Committee</strong>. JO commented that <strong>the</strong> RCAs were
now much more robust and <strong>the</strong> Head <strong>of</strong> Nursing had arranged for Matrons to sign
<strong>the</strong>m <strong>of</strong>f.
The scorecard showed several ‘red’ areas:
• Antibiotic prescribing training non-compliance: D7, D8, ASU, D15, D16, RDU,
D18, Paediatrics and Neonates. The push to get junior doctors through this
training continues.
• Device-related HABs: D5, D16, RDU, Neonatal Unit
• HII1 (CVC Ca<strong>the</strong>ter Bundle) and HII2 (Peripheral IV cannula care bundle) both
relating to Neonatal Unit.
It was agreed that a section for ANTT (Asepsis Non Touch Technique) training
compliance be included on <strong>the</strong> scorecard.
CE
Areas <strong>of</strong> focus over <strong>the</strong> next month:
• Quality <strong>of</strong> RCA documentation and action plans. The need to sign <strong>of</strong>f by Matron
has been discussed at Division 2 Sisters and Matrons meeting
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Agenda Item No. 12.2
• MRSA care pathway ready for trial on D20. Awaiting pathway and
implementation
• ANTT training to be rolled out
• Antibiotic prescribing training
• Hand hygiene – nurses. IP to roll out trial <strong>of</strong> WHO 5 moments observational tool
– to be completed weekly until end <strong>of</strong> December 2009
The Divisional Reports were noted by <strong>the</strong> <strong>Committee</strong>.
7. Pharmacy Report
RF reported:
Division 1
Use <strong>of</strong> cefuroxime and cipr<strong>of</strong>loxacin has fallen substantially since 2007, mainly due
to initiatives aimed at reducing c.diff infection rates, and encouragingly use remains
low. Use <strong>of</strong> <strong>the</strong> carbapenems has increased.
The use <strong>of</strong> cipr<strong>of</strong>loxacin has increased since August, but is above average for use
over <strong>the</strong> preceding 12 month period. ENT required cipr<strong>of</strong>loxacin for <strong>the</strong> treatment <strong>of</strong>
pseudomonas aeruginosa infection. Oncology used cipr<strong>of</strong>loxacin for cholangitis, who
was allergic to penicillin, under <strong>the</strong> advice <strong>of</strong> a Microbiologist. The vascular
department prescribed cipr<strong>of</strong>loxacin for a patient with a pancreatic abscess under <strong>the</strong>
advice <strong>of</strong> a Microbiologist.
The use <strong>of</strong> meropenem has reduced since August but is above average when
compared to <strong>the</strong> previous 11 months. Haematology used meropenem to treat a
patient with CNS pseudomonas aeruginosa infection.
Use <strong>of</strong> cefuroxime has increased since August and is above average when
compared to use over <strong>the</strong> preceding 11 months.
Use <strong>of</strong> ertapenem fell in September and use is below average when compared to
use over <strong>the</strong> preceding 11 months.
The use <strong>of</strong> amoxicillin and co-amoxiclav is now being monitored more closely to
ensure use <strong>of</strong> <strong>the</strong> penicillins is appropriate and justified. With <strong>the</strong> general plan being
to use amoxicillin <strong>the</strong>n co-amoxiclav followed by reserved use <strong>of</strong>
piperacillin/tazobactam. Use <strong>of</strong> co-amoxiclav and piperacillin/tazobactam are
generally falling but use needs to be monitored closely to ensure <strong>the</strong>y are not being
used first line, if not suitable.
Action Points
• Pharmacists are checking that patients with community acquired pneumonia
receive amoxicillin first line and not co-amoxiclav.
• Pharmacists will continue to focus on <strong>the</strong> use <strong>of</strong> carbapenems, due to concerns
<strong>of</strong> resistance developing.
Division 2
The use <strong>of</strong> cefuroxime and cipr<strong>of</strong>loxacin has fallen substantially since 2007, mainly
due to initiatives aimed at reducing c.diff infection rates, and encouragingly use
remains low. Use <strong>of</strong> <strong>the</strong> carbapenems has increased, this is mainly due to <strong>the</strong>
reduction in use <strong>of</strong> <strong>the</strong> cephalosporins and quinolones and partly due to improved
identification <strong>of</strong> penicillin allergic patients thus cautiously using <strong>the</strong> carbapenems in
<strong>the</strong>se patients.
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Agenda Item No. 12.2
The use <strong>of</strong> cipr<strong>of</strong>loxacin has increased since August, but is below average for use
over <strong>the</strong> preceding 12 month period. A&E treated a number <strong>of</strong> patients presenting
with epididymo-orchitis and prostatitis with cipr<strong>of</strong>loxacin. Admissions treated a
patient with a salmonella infection, under <strong>the</strong> advice <strong>of</strong> a Microbiologist.
The use <strong>of</strong> meropenem has reduced since August and is below average when
compared to <strong>the</strong> preceeding 11 months. Admissions treated a patient with an ESBL
UTI under <strong>the</strong> advice <strong>of</strong> a Microbiologist.
Use <strong>of</strong> cefuroxime reduced since August, and is below average.
Use <strong>of</strong> ertapenem reduced since August, and is below average.
The very high peaks in <strong>the</strong> use <strong>of</strong> amoxicillin are related to <strong>the</strong> robotic device in A&E
being filled, this usually occurs every few months.
Action Points
• Pharmacists are checking that patients with community acquired pneumonia
receive amoxicillin first line and not co-amoxiclav.
• Pharmacists are continuing to query <strong>the</strong> use <strong>of</strong> all cephalosporins and
quinolones.
Antibiotic Interventions for September 2009
The total number <strong>of</strong> reported interventions is 122 over <strong>the</strong> month <strong>of</strong> September, a
slight increase compared to last month. The antimicrobial pharmacist started to visit
wards with colleagues in October, to advice and support on antimicrobial prescribing
concerns.
The majority <strong>of</strong> interventions involved <strong>the</strong>: treatment duration (25%), choice <strong>of</strong> drug
and whe<strong>the</strong>r it was for a suitable indication (20%) and dose prescribed (15%).
Treatment Duration
Pharmacists are challenging <strong>the</strong> treatment durations <strong>of</strong> antibiotics and stopping
where necessary. In September prolonged co-amoxiclav, flucloxacillin and
trimethoprim courses were stopped (usually after discussion with a member <strong>of</strong> <strong>the</strong>
medical team).
Choice <strong>of</strong> antimicrobial/indication
Pharmacists are checking that antibiotics prescribed match up with <strong>the</strong> Trust
Antimicrobial Prescribing Guidelines. Co-amoxiclav prescriptions were queried and
changed to amoxicillin where appropriate. Erythromycin prescriptions were queried
and changed to clarithromycin.
Doses <strong>of</strong> antimicrobials
Antibiotics can be sub-<strong>the</strong>rapeutic or toxic if not prescribed at <strong>the</strong> correct dose. The
Antimicrobial Prescribing Guidelines specify doses, thus Pharmacists are checking
that <strong>the</strong> dose prescribed is appropriate. The doses <strong>of</strong> trimethoprim were amended
(confusion between prophylactic and treatment doses), intravenous and oral doses
were also confused for co-amoxiclav.
Allergy Boxes
A patient on D15 had a penicillin allergy written on <strong>the</strong>ir T.S. but <strong>the</strong>y were prescribed
and given 5 days <strong>of</strong> amoxicillin. A patient on <strong>the</strong> admissions ward was prescribed
co-amoxiclav when <strong>the</strong>y had an un-documented penicillin allergy.
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Agenda Item No. 12.2
Action Points
• Pharmacists checking allergy status <strong>of</strong> patients on admission, where time allows.
• Pharmacists checking that penicillin allergic patients are not prescribed
inappropriate antimicrobials.
• Pharmacists endorsing prescriptions <strong>of</strong> co-amoxiclav and piperacillin/tazobactam
with contains penicillin.
Outcome <strong>of</strong> Interventions
There is outcome information for 70% <strong>of</strong> <strong>the</strong> recorded interventions, an increase on
previous months. Pharmacists are trying to ensure that whenever outcome
information is available that <strong>the</strong> detail is added onto <strong>the</strong> intervention sheet. Follow up
is difficult when patients are discharged or move wards. 64% <strong>of</strong> <strong>the</strong> known outcomes
involved <strong>the</strong> Pharmacists advice being taken and <strong>the</strong> Pharmacist dealt with <strong>the</strong> query
<strong>the</strong>mselves in 21% <strong>of</strong> <strong>the</strong> recorded known outcomes.
New Initiatives
The updated antimicrobial prescribing guidelines (revised by Microbiology and
Pharmacy) are due to be published in November.
Antimicrobial prescribing stickers will be in use throughout <strong>the</strong> Trust at <strong>the</strong> beginning
<strong>of</strong> November (copy <strong>of</strong> <strong>the</strong> actual size prescribing sticker and <strong>the</strong> associated
prescribing poster attached to master copy <strong>of</strong> <strong>the</strong> <strong>Minutes</strong>)
Regional Data
The Antimicrobial Pharmacist works closely with <strong>the</strong> WMAPG (West Midlands
Antimicrobial Pharmacist Group) on auditing prescribing and sharing information
across <strong>the</strong> region. Across <strong>the</strong> region on <strong>the</strong> same day, pharmacists carry out a ‘point
prevalence audit’ <strong>of</strong> almost every inpatient. Information collected includes:
• Completion <strong>of</strong> allergy status data
• Whe<strong>the</strong>r <strong>the</strong> patient is on antimicrobials
• Are <strong>the</strong>y on IV antimicrobials
• Duration <strong>of</strong> antimicrobial, if greater than 5 days is it appropriate
• Is <strong>the</strong> stop/review date recorded on <strong>the</strong> chart
Information is <strong>the</strong>n tabulated as in <strong>the</strong> attached table which summarises <strong>the</strong> results <strong>of</strong>
<strong>the</strong> July audit. Results summarised below are for 11 Trusts in <strong>the</strong> Region.
Audit Measure
Number <strong>of</strong> patients
audited
Summary <strong>of</strong> Results from July 2009 Audit
New Cross versus <strong>the</strong> average result
447 patients out <strong>of</strong> a total <strong>of</strong>
3587. NX had <strong>the</strong> 2 nd highest
number <strong>of</strong> patients included,
an achievement as we are not
<strong>the</strong> 2 nd largest Trust.
% <strong>of</strong> patients on antibiotics 26.4% at NX versus an average <strong>of</strong> 28.1%. Thus
fewer <strong>of</strong> our patients are on antibiotics.
% <strong>of</strong> patients on IV
antibiotics
% <strong>of</strong> patients on antibiotics
on IV antibiotics
13% at NX versus an average <strong>of</strong> 12.9%.
49.2% at NX versus an average <strong>of</strong> 45.8%.
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Agenda Item No. 12.2
% with allergy status
recorded
% <strong>of</strong> patients on
antimicrobials where total
course >5 days
% <strong>of</strong> patients on
antimicrobials where total
course >5 days
(Appropriate)
% <strong>of</strong> patients where IV
antibiotics > 48 hours
% <strong>of</strong> patients where stop
or review date
documented
91.9% at NX versus an average <strong>of</strong> 96.1%. Some
Trusts in <strong>the</strong> region have electronic prescribing,
which insists <strong>the</strong> allergy box is completed prior to
<strong>the</strong> prescription being saved, thus <strong>the</strong> average is
quite high.
28.8% at NX versus an average <strong>of</strong> 30.4%. Fewer
<strong>of</strong> our patients are on prolonged antimicrobial
courses.
82.4% at NX versus an average <strong>of</strong> 81.3%. More <strong>of</strong>
our patients on prolonged courses are on
appropriately long courses.
56.9% at NX versus an average <strong>of</strong> 59.5%. Fewer
<strong>of</strong> our patients are on prolonged IV antimicrobial
courses.
23.7% at NX versus an average <strong>of</strong> 62.9%. This
measure is a new audit measure, thus is being
tackled at <strong>the</strong> moment, see action points below. As
o<strong>the</strong>r Trusts have electronic prescribing inclusion <strong>of</strong>
a review/stop date is compulsory, thus <strong>the</strong> average
is quite high.
DL asked if Pharmacy had an action plan to identify <strong>the</strong> Trust’s status against <strong>the</strong>se
indicators and ways <strong>of</strong> improving <strong>the</strong> Trust’s position in <strong>the</strong> league table. RF to bring
an action plan showing a named individual against each action to <strong>the</strong> next meeting.
RF
Action Points
• Pharmacists checking that all antimicrobials prescribed are necessary and in line
with <strong>the</strong> Trust Antimicrobial Prescribing Guidelines.
• Pharmacists checking that patients are changed from IV to oral as soon as
appropriate to do so.
• Pharmacists are completing <strong>the</strong> allergy box where possible.
• Pharmacists are checking <strong>the</strong> appropriateness <strong>of</strong> all prolonged courses in line
with <strong>the</strong> Trust Antimicrobial Prescribing Guidelines.
• Pharmacists will be rolling out <strong>the</strong> antimicrobial prescribing stickers in early
November; <strong>the</strong> sticker asks for <strong>the</strong> stop/review date to be stated when an
antimicrobial is prescribed (see new initiatives). This information can <strong>the</strong>n be
used by Pharmacists to stop or review antimicrobials.
The Pharmacy report was noted and accepted by <strong>the</strong> <strong>Committee</strong>.
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Agenda Item No. 12.2
8. Performance
CE talked to <strong>the</strong> DIPC report in <strong>the</strong> absence <strong>of</strong> MC:
SPCC charts relating to September 2009 had been circulated to <strong>the</strong> group and were
self-explanatory.
No MRSA bacteraemias during September. For <strong>the</strong> first time <strong>the</strong> Trust had gone an
entire quarter without an MRSA bacteraemia. On 21 st September it had been 120
days since <strong>the</strong> last MRSA bacteraemia, and as at <strong>the</strong> date <strong>of</strong> this meeting <strong>the</strong>re had
been no instances.
Only one MSSA bacteraemia attributable to RWHT in September, and only two in
total for Wolverhampton. Still over target for MSSA bacteraemias, but we are now
moving back towards <strong>the</strong> target ra<strong>the</strong>r than fur<strong>the</strong>r from it.
MRSA acquisition is only just within target for each Division and for <strong>the</strong> Trust overall.
Although VSU had two cases, <strong>the</strong>se were <strong>the</strong> first <strong>the</strong>y had had since January 09,
which was considered a magnificent performance from what was once one <strong>of</strong> <strong>the</strong>
highest risk wards. D16 remains a problem, though <strong>the</strong>ir total was less than in
August. D15 has also had a problem with this in September. The IPT has been
working with <strong>the</strong>se wards to help resolve any issues that might have contributed to
this.
C. difficile infections were at <strong>the</strong>ir lowest since February 2009, with five cases
attributable to RWHT according to internal definitions and three cases using <strong>the</strong> DoH
definition. Against our Trust internal target, although we remain above <strong>the</strong> target, it is
<strong>of</strong> note that <strong>the</strong> Trust is moving closer to <strong>the</strong> target; at one stage it was 10 cases
over, but now five cases over. D16 had two cases during <strong>the</strong> month, but <strong>the</strong>re is no
apparent connection between <strong>the</strong>se, which occurred more than three weeks apart.
Overall scorecard for <strong>the</strong> Trust and Divisions is totally green, but MRSA acquisition
was very close to yellow.
ESBLs were again high in <strong>the</strong> community. CE commented that <strong>the</strong> worrying aspect
regarding ESBL is that it is not fully understood. GE agreed to arrange a mapping
exercise to establish more information. DL asked that it be noted how disappointed
he was with <strong>the</strong> lack <strong>of</strong> progress around <strong>the</strong> necessity to reduce ESBLs, and it was
unacceptable for <strong>the</strong> Trust to be in a position where incidents <strong>of</strong> ESBLs are not
understood.
Hand hygiene data for September was not yet available.
Hand hygiene training remains static at 82%. Only three groups <strong>of</strong> staff are hitting
<strong>the</strong> target <strong>of</strong> 85%, but a fur<strong>the</strong>r four groups fall between 80 and 85%.
Antibiotic prescribing is low, but recently <strong>the</strong>re have been several well attended
sessions, so this should see an increase next month. Compliance among senior
medical staff is 95% in both Divisions.
Much better month for blood culture contaminants, with Paediatrics having six,
compared with 12 last month.
20 HABs, with 11 DRHABs, <strong>the</strong>refore within target. Lines are <strong>the</strong> predominant cause
<strong>of</strong> DRHABs, with at least six and possibly eight due to lines. CE expressed concern
that lines were part <strong>of</strong> <strong>the</strong> problem. Neonatal Unit gives <strong>the</strong> appearance <strong>of</strong> being a
problem area, but <strong>the</strong>re are many unique difficulties with diagnosing and attributing
<strong>the</strong>se infections, and much <strong>of</strong> what is stated as best practice in <strong>the</strong> care bundles are
not relevant to this group <strong>of</strong> patients.
GE
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Agenda Item No. 12.2
9. Health Economy <strong>Infection</strong> <strong>Prevention</strong> Forum – Terms <strong>of</strong> Reference
CE referred to <strong>the</strong> document circulated to <strong>the</strong> group – ‘Care Acquired <strong>Infection</strong> (CAI) :
Strategic Wide Arrangements and <strong>Committee</strong> : Terms <strong>of</strong> Reference. The document
required approval <strong>of</strong> <strong>the</strong> IPCC prior to presentation at Trust Board. DL and CE will
be members <strong>of</strong> <strong>the</strong> <strong>Committee</strong>. It was agreed that <strong>the</strong> document should go to
December 2009 Trust Board.
10. Report <strong>of</strong> LNIP
SH reported:
Outbreaks / Incidents
Nil to report
Audit and Surveillance Activity
Sharps practice and PPE audit report in progress for next meeting
Isolation audit report attached
MRSA admission screening
Emergency admissions: 94%
Elective admissions: 96%. CE asked SH to identify <strong>the</strong> reason for 4% elective
admissions not being screened.
SH
Education
E learning package fur<strong>the</strong>r problems from IT <strong>the</strong>refore not released for general use.
DVD replaced training sessions to support redeployment <strong>of</strong> non clinical staff through
September –November 2009.
Five moments updates provided for Matrons and cardiology prior to launch <strong>of</strong>
observational tool.
Staffing
Nil new to report
Policies
TSE under review
Appendix to Isolation policy for Renal Dialysis (attached)
Showcase
Integuseal
RRP 1 product being used in <strong>the</strong>atres (Sept - Nov) by cardiac, colo-rectal and
vascular surgeons.
Quality Compass
The contract for use <strong>of</strong> <strong>the</strong> system will cease 31/10/09. Evaluation report to be
generated with input from NHS Technology Adoption Centre.
ATP Bioluminescence
Loughborough University have approached RWHT to undertake a study to ascertain
what frequency and test points are required to use such a system optimally.
LoTrache ET Tube Study
A meeting had recently taken place and proposal for <strong>the</strong> study was discussed; in
principal Chris Gush is encouraged at <strong>the</strong> potential <strong>of</strong> <strong>the</strong> proposed study. Proposal
to be generated for submission to Showcase Hospital programme for review.
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Agenda Item No. 12.2
CE asked SH to explore <strong>the</strong> possibility <strong>of</strong> a trial <strong>of</strong> non-touch gel dispensers when <strong>the</strong>
contract for <strong>the</strong> current dispensers expires, to improve hand hygiene. JV reported
that <strong>the</strong> current dispensers drip gel after use which could prove hazardous.
SH
11. Any O<strong>the</strong>r Business
11.1 Acoustic Tracking System
CE informed <strong>the</strong> meeting that Paul Cryer (DoH) was looking for a site to
implement <strong>the</strong> Acoustic Tracking System and had arranged a presentation at
<strong>the</strong> Trust for today. The system tracks patients requiring isolation in <strong>the</strong> Trust.
10. Date <strong>of</strong> Next Meeting
Thursday 26 th November 2009, 10.00am, Conference Room, Hollybush House.
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