Queen Elizabeth University Hospital and Royal Hospital for Children Case Note Review Overview Report March 2021

Every GNE bacteraemia occurring in a Paediatric Haematology Oncology patient at NHS GGC should be comprehensively investigated using RCA methodology, whether or not it is considered at the outset to be related to the hospital environment or thought to be part of a potential outbreak. This will ensure that future consideration of the underlying issues can be informed by consistent, comprehensive and prospectively collected data.

A multi-professional group, with a defined and consistent membership representing all appropriate skills and backgrounds, should be established with responsibility for continuing oversight of these data: for assessment of its quality, and completeness, and for its analysis and reporting. The intent is that this group, which should have external representation, will grow in collective expertise and knowledge; have a shared understanding of the history and challenges encountered since the opening of the new QEUH/RHC site; and will be able to define and guide the organisation’s response to future concerns about environmentally acquired infection in this group of patients. The group should report directly to the IPC Manager and Lead Infection Control Doctor and its findings form a standard part of upward reporting of IPC issues within NHS GGC.

Given the unexplained but significant excess of female patients in the Case Note Review, the Paediatric Haematology Oncology service should audit all bacteraemias for a sufficient period either to reassure that there is no real gender effect, or to investigate further if this proves to be the case.

The data systems used to document facilities maintenance activity in clinical areas need to consistently capture the exact location of the work done; the date(s) on which the work was actually done; and be accessible to inform the IPC process, including the investigation of clusters and outbreaks.

The frequency with which facilities maintenance activities occur in specific ward areas should be reported on a regular basis in a way that informs wider awareness of the vulnerability of the environment and tracks changes in the pattern of such activity.

The precise location of any swab or water sample taken for microbiological surveillance, and the date on which it was obtained, must be recorded and the results made accessible to inform the IPC process, including the investigation of clusters and outbreaks.

When a suspected infection outbreak is being investigated, the plans agreed for environmental sampling of the relevant area must demonstrate a systematic approach appropriate to the circumstances of the investigation.

When the Chair of an IMT (or similar future structure) identifies that environmental samples are required to inform an investigation, these should be taken, reported back promptly and evidenced in the IMT minutes.

A systematic, fit for purpose, routine, microbiological water sampling and testing system is required to provide assurance going forwards. How the results from such sampling/testing are recorded, accessible and used to highlight concerns should be reviewed, including to ensure that investigations of possible links between clinical isolates and water/environment sources can be informed in a timely way. In addition, investigations of possible links between clinical isolates and water/environment sources should consider whether (short or medium/long term) changes to the routine microbiological water sampling and testing system are required.

NHS GGC should ensure that the SOP for Minimising the Risk of Pseudomonas aeruginosa infection from water explicitly states whether this also applies to high risk areas other than adult and paediatric intensive care units and neonatal units.

NHS GGC should review the current approach to IPC audit: a) to ensure that the component elements are addressed individually and that the RAG rating is not determined only by an overall score; and b) to show that the governance and assurance process relating to improvement action plans can demonstrate if interventions have been effective. Quality improvement methodology should be used to drive and sustain improvement.

The current status of IPC audit should form a routine and documented component of IMT assessment.

Greater effort should be made to ensure that deficits identified by IPC audits are remedied, re-audited, linked to measures of ongoing quality improvement/compliance, and clearly documented.

Greater attention should be paid to the evidence for benefit from Enhanced Supervision by demonstrating sustained improvement in standards where this approach is introduced to a clinical area.

The validity of Hand Hygiene audits should be strengthened by ensuring the staff sample audited is sufficiently representative in terms of numbers and types of staff; and that effectiveness of the interventions are monitored to demonstrate sustained improvement.

The frequency of Hand Hygiene audits should be increased when there are concerns about infection rates potentially related to the environment

NHS GGC should ensure better communication between the Microbiology and IPC teams. We recommend a forum by which sharing of information and actions occurs in real time to support and improve quality of care to patients, maintain progress and discuss action for any potential change in a patient’s condition or linked infections.

NHS GGC should review the ICNet alert organism list to ensure that, at a minimum, it reflects the advice in the Scottish NIPCM and to ensure that it is further updated to reflect experience with GNE bacteraemias.

NHS GGC should review its Standing Operating Procedure regarding the use of the term HAI to make it clear whether this includes all Healthcare Associated Infections. This is a specific issue in the context of patients who, like those in Paediatric Haematology Oncology, frequently and repeatedly attend the hospital as outpatients, day patients and inpatients and for whom the distinction between Hospital Acquired Infection (HAI) and Healthcare Associated Infection (HCAI) is unlikely to be useful.

NHS GGC should revisit how they will monitor and, if necessary, trigger concerns about future outbreaks of Gram-negative environmental infections. Relaince on SPC charts to determine if episodes of infection caused by unusual/uncommon microorganisms are significant should be re-evaluated. The process in place for much of the Review period appears to have been insensitive to identifying clusters that should have raised earlier concerns about potential for a common/environmental source of infection.

NHS GGC should consider the further and consistent use of the RCA process across the organisation a) to identify evidence of common themes as a cause of infection over time; and b) what can be extracted from the RCA process for organisational learning and improvement.

NHS Scotland should consider if this approach should become a recommendation in the NIPCM.

RCA methodology should become the standard approach to the investigation of serious infections in Paediatric Haematology Oncology patients.

The IPC Team should ensure IMT minutes are filed with all supporting papers so that a complete record of the discussions held, evidence presented, actions agreed and the overall report concluding the process, is available and accessible in a single place.

The IMT action log should be a continuous and evolving document throughout all meetings in an IMT series. The log should be reviewed and updated at each meeting so that there is a clear record of actions agreed, responsibility held and tasks completed. The IMT should not be closed if there are actions which have not been completed.

The absence of IMT reporting at the closure of an IMT sequence is a breach of NHS GGC’s own policy. This should be remedied so that practice complies with policy.

In addition to confirming that due process has been followed in line with organisational policy, IMT and other IPC reports intended for upward reporting within the organisation should more fully describe the scale and significance of the incident that has been investigated from the patient perspective.

NHS GGC should assure that the governance of the IMT process, its reporting and escalation to Board level, is clearly defined and followed; and that an audit trail of all evidence related to any suspected or actual outbreak is clearly documented and fully reported.

NHS GGC must (continue to) develop a comprehensive and searchable database that allows details of microbiology reference laboratory reports to be compared between samples of the same bacteria obtained from different patients or environmental sites.

The system for integrating microbiology reference laboratory reports into the patient microbiology record needs to be reviewed and strengthened. Similarly, the system for ensuring that microbiology reference laboratory information is available to and used by the IMT process, including the investigation of clusters and outbreaks, needs to be reviewed and strengthened.

NHS GGC should undertake a review of the current effectiveness of the system for collating, storing and integrating both scanned hand written records and digitally recorded records and how this achieves an accurate, accessible and chronologically accurate health record for each patient.

NHS GGC should clarify their strategy for further evolution towards fully digital records

Consideration should be given to the integration of the microbiology recommendations regarding the diagnosis and management of infections, as currently documented in the Telepath patient notepad, into the patient clinical record.

It should not be possible to code patient activity to a clinical area in which the patient was not present: this should be addressed.

The Paediatric Haematology Oncology service should engage with regular reporting and analysis of adverse events. Admission to PICU is an obvious way of identifying, for audit purposes, the patients most likely to have the most serious (Category I) AE.

The PTT offers a useful tool to identify and monitor trends in the occurrence of adverse events that occur during care.

NHS GGC should assure and report consistent utilisation of the Datix system, and audit the validity of the classification and risk categorisation given to incidents by its staff.

The Paediatric Haematology Oncology service should review the practice of ‘challenging’ central venous lines in line with evidence for its risks and benefits.

When it is agreed that a central line should be removed for optimal management of a patient’s infection, operating theatre and anaesthetic resources must be made available to ensure its prompt removal (within 24 hours).

The Paediatric Haematology Oncology service should ensure that a decision not to remove a central venous line contrary to the advice of the microbiologists is always documented in the medical record.

The Paediatric Haematology Oncology service should ensure that Morbidity and Mortality reports are not restricted to a review of patients who die. Future GNE infections should be used as a trigger for an M&M review; to assess management and outcome; and with the inclusion of an action plan to identify approaches to reduce risk and improve care.

International consensus guidelines have recently been published for use of antibiotic prophylaxis in Paediatric Haematology Oncology. These should be reviewed by both the service and by the Managed Service Network, and local and network policy and practice should be amended accordingly.

The Paediatric Haematology Oncology service should audit the use of antibiotic prophylaxis against the new policy once implemented.

The Managed Service Network and NHS GGC should review any changes to the use of shared care that have evolved as a result of the service disruption experienced in recent years, and ensure the structures and processes in place adequately address patient safety and staff support across the shared care network.