Agenda item

Susan Acott (Chief Executive, Dartford and Gravesham NHS Trust), Annette Schreiner (Medical Director, Dartford and Gravesham NHS Trust), Patricia Davies (Accountable Officer, NHS Dartford, Gravesham & Swanley CCG and NHS Swale CCG), Richard Miller-Holliday (Interim Deputy Chief Nurse, NHS Dartford, Gravesham & Swanley CCG) and Nicola Jones (Head of Quality & Safety, NHS Dartford, Gravesham & Swanley CCG and NHS Swale CCG) were in attendance for this item.

(1)       The Chairman welcomed the guests to the Committee. Ms Acott began by explaining that hospitals were high risk for  infections as patients included those who were admitted due to an infection, those who were immunosuppressed or very unwell  and those receiving treatment with side effects which made them prone to infections; in addition to infections which were antibiotic resistant. She highlighted the importance of infection prevention and control at the Trust; data relating to a number of infections including MRSA, E.coli, C. difficile and MSSA was publically published and monitored by the Trust’s board as a measure of infection prevention and control.

(2)       Ms Schreiner explained that the Trust reported monthly to Public Health England on acquisitions of MRSA, E.coli, C. difficile and MSSA. She noted that 3% of the population carried MRSA on their skin and infection occurs if there is a break in colonised skin. She reported that E.coli was often linked to catheter acquired infections and C. difficile affected people recently treated with antibiotics. She stated that up until February 2015 there had been no MRSA acquisitions at the Trust for 12 months. In April 2015 the Trust moved from universal to targeted screening following advice published by Public Health England in 2014. In summer 2015 the infection prevention and control team had been affected by long term sickness and the teaching programme fell behind. She noted that there were 14 MRSA acquisitions at the Trust in 2015/16; five between the introduction of targeted screening in April 2015 and 19 December 2015 and nine between 20 December 2016 and 25 February 2016 which was outside of acceptable and expected levels. She reported that universal screening was reintroduced on 25 January 2016 and there had been no further acquisitions since 26 February 2016; a large number of MRSA colonised patients were identified following the reinstatement of universal screening which was reducing. She reported that there had been no cases of C. difficile and MSSA since March 2016 and there had been a very low number of cases of E.coli.

(3)       Ms Schreiner stated that in March 2016 all of the infection prevention and control team had left the organisation due to retirement, long term sickness and personal reasons; NHS Dartford, Gravesham and Swanley CCG seconded an infection prevention specialist nurse to the Trust to stabilise the interim team whilst permanent staff were appointed. A taskforce met every two weeks to implement the action plan following the TDA inspection visit in March 2016. As part of the action plan, daily MRSA huddles took place every morning to coordinate work streams. The Trust had introduced a communication strategy for all staff and wards focusing on hand hygiene, cleaning and decontamination.  The Infection Control Committee was now meeting monthly, instead of quarterly, to address the MRSA issues and a Non-Executive Director now attended this Committee on behalf of the Board. She highlighted that occupancy and infection rates were linked; infection rates rose when occupancy was over 85%. She stated that the Trust had had 100% occupancy since April 2015 and peaked at 107% in February 2016. She explained that the Trust was concerned about the occupancy rates, particularly due to the development of the Thames Gateway and Ebbsfleet Garden City.

(4)       Mr Miller-Holliday gave an overview of the CCG’s response to the MRSA incidences at the Trust. He explained that the CCG had initially raised concerns about infection prevention in March 2015; a table top exercise in May 2015 was carried out which identified key recommendations. Due to a lack of consistent infection prevention team in 2015, no sustainable improvements were made. The CCG considered issuing a Contract Performance Notice but, as the Trust had gone two months without reporting a further case, it was not implemented. In January 2016 the CCG issued a Contract performance Notice and placed them under a Remedial Action Plan. He stated that the Trust Development Authority visited the Trust in March 2016 and implemented an improvement plan which was monitored weekly in a telephone conference call between the Trust, NHS Improvement (formerly the Trust Development Authority) and the CCG. He noted that monthly verbal updates were given to the North Kent HCAI Assurance panel meetings and bi-monthly quality assurance meetings with the Trust. He noted that the CQC and NHS Improvement would revisit the Trust in late June following their visit in May 2016.

(5)       Members of the Committee made a number of comments and asked a series of questions. A number of comments were made about acquisition and reducing occupancy. Ms Schreiner explained that a hospital acquired MRSA infection was an infection which was not present at admission or occurred more than 48 hours after admission. She stated that the Trust had undertaken interventions in three surgical and three medical wards including the implementation of a screening tool. She noted that if an area became MRSA positive, a deep clean of the area and additional screening for neighbouring patients was undertaken. She reported that in May there had only been 4 – 8 acquisitions in two wards. Ms Acott reported that the Trust’s had plans to increase its clinical footprint to reduce occupancy and accommodate the new housing growth. She explained that only 55% of the hospital building currently provided direct medical care; the Trust was looking to move administrative and clerical staff out of the hospital building to enable the installation of additional beds. The Trust was also looking to transfer elective surgery to Queen Mary’s Hospital in Sidcup. She noted that the Trust had recently carried out a five year retrospective and had identified a number of factors which had led to delayed discharges and high occupancy rates including population growth with aging population and high fertility rate; increased activity following service changes at St Mary’s Hospital; and greater patient acuity.

(6)       Members enquired about the Public Health England guidance which recommended targeted screening. Ms Acott stated that the guidance had seemed reasonable as the Trust had not had an MRSA acquisition for a year when implemented. She noted the Trust’s intention to write to Public Health England to request a review of the guidance. She explained that the Trust had been caught off guard and it highlighted the need to evaluate the adequacy of its systems and processes. Ms Schreiner noted that the Trust was unlikely to revert to targeted screening if similar guidance was published in the future. Mr Scott-Clark stated that infection control was fundamental for providing quality care and this incidence had highlighted the importance of due diligence. Ms Davies stated that there had been recognition by the Trust of a lack of due diligence and the Trust had made significant improvements under the action plan. She was assured that it was not a wider culture issue.

(7)       In response to a specific question about the cost of reinstating universal screening, Ms Schreiner stated that it had cost around £30,000 in consumable materials, such as swabs, for universal screening since January 2016; in addition to staff time and lab costs. Ms Acott noted the costs would be ongoing as the Trust admitted over 200,000 patients per year.  She explained that there had also been costs for targeted screening, there had been an individual cost to the 14 patients who had contracted MRSA in 2015/16. The Trust had also incurred additional costs for the antibiotics to treat the infections, increased length of stay for affected patients and deep cleaning services. The Trust had undertaken a review of the cleaning arrangements with its facilities management contractor. She stated that the MRSA incidences did not result in any cancellations.

(8)       RESOLVED that:

(a)       the reports provided by Dartford and Gravesham NHS Trust and NHS Dartford, Gravesham and Swanley CCG  be noted;

(b)       Dartford and Gravesham NHS Trust be requested to provide an update to the Committee in six months;

(c)        the Chairman write a letter to the Secretary of State for Health and Chief Executive of Public Health England requesting a review of the  Department of Health guidance on targeted admission screening for MRSA. 

After the meeting, the Vice-Chairman-in-the-Chair received clarification from the Trust regarding the guidance referred to in the meeting. The guidance was not by Public Health England, it was instead the Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)‘s ‘Implementation of modified admission MRSA screening guidance for NHS (2014)'

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf