Queen Elizabeth University Hospital/NHS Greater Glasgow and Clyde Oversight Board: interim report

Infection Prevention and Control

40. Long before the recent incidents at the QEUH, IPC procedures in hospitals had been under a spotlight. Following an outbreak of Clostridium difficile infection at the Vale of Leven Hospital within NHS GGC, which led to the deaths of 34 patients, the Scottish Government established an Inquiry under Lord MacLean to investigate not just C. difficile infection, but all deaths at the hospital associated with this infection in the period between 1 December 2007 and 1 June 2008. Its final report was published in November 2014^[5], and found, amongst other things, that:

• governance and management failures within NHS GGC had created an environment in which patient care was compromised and the approach to IPC was inadequate;
• there were significant deficiencies in IPC practices and systems which had had a profound impact on the care provided to patients in the hospital; and
• strong management was lacking, which contributed to a culture unsuited to a caring and compassionate hospital environment.

41. NHS GGC accepted the recommendations, which included the following of particular relevance to the Oversight Board's work (not all directed exclusively at the Health Board, but across NHS Scotland more widely):

• In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible for all patient services before the reorganisation takes place. Subsequent to that reorganisation regular review s of the process should be conducted to assess its impact upon patient services, up to the point at which the new structure is fully operational. The review process should include an independent audit.
• In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place for the success of the project and the maintenance of patient safety throughout the process.
• Health Boards should ensure that IPC policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government, and in any event at specific review dates no more than two years apart;
• Health Boards should ensure that all those working in a healthcare setting have mandatory IPC training;
• Health Boards should ensure that the Infection Control Manager (ICM) has direct responsibility for the IPC service and its staff;
• Health Boards should ensure that the ICM reports direct to the Chief Executive or, at least, to an executive board member;
• Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings;
• Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time; and
• Health Boards should ensure that IPC groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.

42. The Vale of Leven Inquiry provides important context here. Not only did the Health Board set out plans to implement all the relevant recommendations, but the recommendations as a whole helped to shape the development of national standards and the current framework for IPC across NHS Scotland. This culminated with the issuing of the key guidance letter, DL (2019) 23 in December 2019^[6] by the Chief Nursing Officer of NHS Scotland. This set out the mandatory Healthcare Associated Infection (HCAI) and Anti-microbial Resistance (AMR) policy requirements for all NHS Scotland healthcare settings. As the letter noted:

"Despite the progress made over recent years, reducing HCAI and containing AMR remains a constant challenge. Therefore, it is important at both a national and NHS Board level and beyond, that there is ongoing and increased monitoring for accurate, and, as far as is possible, real time assessments of current and emerging threats."

43. This background of increasing sensitivity to the need for ever-more robust IPC procedures and the drive for improvement form an important backdrop for the Oversight Board's work. In its terms of reference, the Oversight Board recognised that there would be key points of learning and need for improvement for both NHS GGC individually as well as for NHS Scotland as a whole. In this context, it is important to understand the distinctive circumstances of what took place in the QEUH.

• The unique circumstances of a modern, large hospital. There was little precedent for the challenges arising from a large, newly-built hospital complex such as the QEUH – not least in understanding the scale and nature of the infection issues and the diversity of organisms that appeared. This manifested itself in the limited experience that NHS GGC – and NHS Scotland more widely – could draw upon to fathom the particular issues relating to infection in the context of a modern hospital such as the QEUH. Indeed, there are few comparators whose experience on which the Health Board has been able to draw. This context is by no means justification for any of the actions taken – or not taken – as standards should rightfully be expected to be met in all healthcare settings. However, it is essential for understanding how NHS GGC had to adapt to an often novel, and in many respects, 'non-textbook' situation. Recognition of this is important, not least from the perspective of the national learning the Health Board's experience can provide going forward.
• The scale of the Health Board. The issue of NHS GGC's unique scale as the largest Health Board in Scotland (and one of the largest in Europe) is relevant, as the sheer size and expanse of the Health Board were defining features for some of its approach to these issues. For example, IPC responsibilities are divided between a number of different geographical teams, each covering a mixture of hospitals and other healthcare settings. The Oversight Board's comments are largely focused on the operation of processes at the QEUH. At no point was the issue of scale ever offered as a mitigating or explanatory factor for how the Health Board should have fulfilled its responsibilities in the circumstances under review. However, it was cited as a factor at points in how the Health Board did and could have responded to the circumstances and what might be improved going forward.
• Focus on selected aspects of IPC. Throughout the Oversight Board's work, there were many good examples presented of a range of IPC functions in NHS GGC. As a result, it is important to separate out issues that applied specifically to the particular infection incidences under review – both in terms of the specific site (the QEUH) and the specific patient group (those in the paediatric haemato-oncology service) – and those which applied more widely to how IPC was pursued across NHS GGC as a whole. For example, the Oversight Board did not set out to examine the experience, responsibilities and processes in place for dealing with the bulk of gram-positive infections, and the steps that the IPC Team and other staff had taken to eradicate their transmission (such as approaches to hand cleanliness). This is especially important in understanding the Oversight Board's focus on IPC in the context of environmentally-related infections (which includes both gram-negative and positive organisms). Consequently, the Oversight Board did not examine the full range of IPC functions in NHS GGC, only those directly relevant to these particular incidents.

44. At the same time, there is a historical context that should be understood. While not delving into these issues, as already noted, the Oversight Board recognised that there were significant shortcomings in: the construction and handover of the QEUH; and how NHS GGC responded to emerging and related problems. These include the concerns that were raised by a number of clinicians at an early stage as well as how 'warning signals' about potential problems were – or were not – acted upon over the years. The Oversight Board discussed these issues, but they have only been highlighted where they: remained a continuing and current factor that would compromise any assurance on the issues relating escalation; or were corrected and led to improvements that are important to acknowledge. It is recognised that relationships and trust were impacted as part of these historical issues, resulting in the early decisions to appoint Professors Marion Bain and Angela Wallace in key positions within the Health Board to take forward urgent work.

45. Ultimately, the Oversight Board has sought assurance that current IPC processes within NHS GGC are 'fit for purpose': in terms of national standards and good practice and in light of how they addressed the infection incidents of the last few years. In this respect, the Oversight Board has measured Health Board IPC against the key success factor: "the current approaches that are in place to mitigate avoidable harms, with respect to IPC, are sufficient to deliver safe, effective and person-centred care" (see Annex D). Consequently, the Oversight Board commissioned a range of work. As part of this programme, the Oversight Board has:

• commissioned a detailed description of the timeline of infection incidents between 2015 and 2019 and formal meetings to address the incidents (this will be presented in full in the Final Report);
• commissioned a system-wide Peer Review of current IPC systems and processes and associated governance scheme of delegation and escalation mechanisms against relevant national standards and guidance;
• commissioned bespoke SBARs on particular issues, such as the use of HIIATs by the Health Board;
• received reports from key individuals placed within NHS GGC, particularly Professors Bain and Wallace; and
• assessed if there were any gaps when mapped against national standards and guidance and, if so, identify areas for improvement and shared learning with respect to operational delivery of IPC, including staffing/resourcing, minimum skills and joint working between relevant units.

46. As noted already, some work could not be done in full due to curtailment caused by the Covid-19 pandemic. Nevertheless, the Oversight Board amassed sufficient evidence to set out a series of findings in the following key areas:

• Processes and systems: the degree to which specific IPC processes and systems have been aligned with national standards and good practice and their effective and reliable implementation; and
• Approach to improvement: the extent to which the IPC Team has demonstrated a sustained commitment to improvement, and acted as an agent for improvement in infection management across NHS GGC.

Other IPC issues – and overall view of the efficacy of IPC within the Health Board – will be set out in the Final Report.

Processes and Systems

47. A critical element of the work of assurance by the Oversight Board is IPC processes and procedures within the Health Board. National compliance is important, not least given the efforts in recent years to codify good practice in IPC in the wake of the Vale of Leven Inquiry. There is a recognisable balance between compliance in national standards with flexibility in applying local innovation/ improvement, but as with much healthcare, fidelity in crucial areas is important.

48. To examine in greater detail the way that IPC operated within NHS GGC, a Peer Review was commissioned by the Oversight Board to explore some processes and procedures in more forensic detail. This exercise was designed to gain an understanding of how IPC systems and processes were embedded. The objectives of the Review were to:

• investigate the ways in which IPC at NHS GGC is operationalised across the system; and
• determine the ways in which national policy has been implemented within NHS GGC, identifying areas where this was carried out and where it could be improved.

The focus has been on the current operation of these processes.

49. Several areas of focus were originally identified for the Review, but owing to the restrictions caused by the Covid-19 pandemic, only the following could be taken forward:

• implementation of the National IPC Manual (NIPCM);
• implementation of Healthcare Associated Infection Systems for Controlling Risk in the Built Environment (HAI-SCRIBEs);
• audit;
• surveillance; and
• the use of the Healthcare Infection Incident Assessment Tools (HIIATs).

Action on two other areas – outbreak and incident investigation, and water safety – could not be taken forward through this Peer Review as planned, but are still recommended to be examined at some stage.

50. A team comprising members of the Infection Prevention and Control and Governance (IPCG) Subgroup was established to undertake the Peer Review. The Peer Review was undertaken on 16 March 2020 by Lesley Shepherd (national professional advisor to the Scottish Government) and Frances Lafferty (Senior Infection Control Nurse in NHS Ayrshire and Arran). Additionally, the Oversight Board requested Anti-microbial Resistance and Healthcare Associated Infection (ARHAI) Scotland to undertake an assessment of NHS GGC reporting of Healthcare Infection Incidents, specifically relating to the QEUH site. The focus of the SBAR was on how HIIATs were used.

Application of the National IPC Manual

51. As set out above, over the last few years there has been significant work nationally to set a common approach to improvement and standards in IPC. Central to this has been the NIPCM. Published in 2012^[7], the National Manual sets out the standards, good practice and resources for improvement for IPC across NHS Scotland. Alignment between Health Board practice and the NIPCM reflects a Health Board's commitment to a recognised, consensus set of practices associated with 'what good looks like' for IPC. The NIPCM aims to:

• facilitate the effective application of IPC precautions by appropriate staff;
• reduce variation and optimise IPC practices throughout Scotland;
• improve the application of knowledge and skills in IPC;
• reduce the risk of HAI; and
• help alignment of practice, education, monitoring, quality improvement and scrutiny.

52. The National Manual is central to the Health Board's approach to IPC – indeed, NHS GGC placed the NIPCM as a link on the IPC Portal on its intranet site. In addition, the IPC Team has developed a series of new 'Standard Operating Procedures' (SOPs) to supplement national guidance for the Health Board – NHS GGC described these as a way of 'operationalising' the NIPCM, making it easier for frontline staff to understand the Manual.

53. However, as the aim of the NIPCM has been to "make it easy for care staff to apply effective infection prevention and control precautions", it was not clear to the Peer Review team why NHS GGC has developed so many SOPs. These typically require regular updating based on the current scientific evidence reviews within the NIPCM. The SOPs do not provide contradictory information – they reflected national advice – but given that this work has already been undertaken as part of the NIPCM, the production of the SOPs seems to be unnecessary, if not redundant.

54. Moreover, the NHS GGC IPC Portal does not differentiate between local SOPs and the NIPCM. This is likely to cause confusion as to what constitutes national policy and what, local guidance. Moving forward, NHS GGC must ensure that staff are directed initially to the NIPCM and that SOPs should only be provided where there is a clear, compelling justification for their added value.

55. Nevertheless, there are some SOPs that should be developed going forward. In particular, disease-specific SOPs or aide-memoires would be a useful tool for facilitating easy access to key IPC information supported by the NIPCM. This could be important for novel and emerging pathogens which were linked to significant outbreaks of infection. The NIPCM includes information around transmission-based precautions required for specific pathogens/conditions within its Appendix 11, but there is a national need for extra guidance. It would be appropriate for some additional disease-specific, evidence-based SOPs/aide memoires to be produced nationally for inclusion within the NIPCM as part of national work.

Use of Healthcare Associated Infection Systems for Controlling Risk in the Built Environment

56. HAI-SCRIBE implementation was chosen as part the Peer Review to illuminate the wider issues of IPC governance being considered by the Oversight Board. HFS published the Scottish Health Facilities Note (SHFN) 30^[8] in January 2007 to support Health Boards to manage IPC in the built environment. The guidance comprised:

• Part A – the National Manual, which provides information for teams to support decision making so that identified risks can either be eliminated or successfully managed; and
• Part B – the HAI-SCRIBE Implementation Strategy and Assessment Process, which supports built environment project groups to identify, manage and record built environment infection control risks.

The main aim of the guidance is to ensure that IPC issues are identified, analysed and planned for at all stages of a project in the healthcare built environment. HAI-SCRIBE ensures that IPC measures are designed as part of plans and can be maintained throughout the lifetime of the healthcare facility.

57. The Peer Review team found that while this process is largely adopted within NHS GGC, there are inconsistencies. When both the Facilities and Estates staff and Lead Infection Control Nurses (LICNs) were asked if there was a consistent and systematic approach to HAI-SCRIBE risk assessment across NHS GGC, their answers differed: Facilities and Estates representatives stated that there was, while the LICNs said there was not. Moreover, a review of a selection of completed HAI-SCRIBE documents highlighted:

• inconsistencies in approach regarding levels of work, patient risk categorisation and subsequent control measures required to mitigate risk to patients;
• evidence of involvement of the IPC Team in compiling the document, when it was often the responsibility of the relevant Estates Manager;
• inconsistencies within the documentation in terms of the type of work and control measures as well as those personnel involved in the document completion – for example, the names of those involved were found on the front of the HAI-SCRIBE document, however, at the foot, there were no signatures and on occasion, a different LICN noted; and
• an impression that several had been 'cut and pasted' from previous HAI-SCRIBE documents.

58. Good practice is clear that this should be a joint responsibility between Facilities and Estates and IPC Team staff, ensuring that the approach to reporting does not become siloed and relevant expertise and judgement is systematically and appropriately deployed.

Approach to Audit

59. In 2018, HPS issued the National Monitoring Framework for Safe and Clean Care Audits^[9], which provides an agreed, recommended minimum approach to auditing for all Health Boards. This gives a set of principles for the quality assurance of all Safe and Clean Care auditing while supporting a Quality Improvement (QI) approach for compliance and improvement. The Framework clearly defines where the responsibility for undertaking audits, developing action plans and taking forward actions to address any issues lies. It stresses that IPC within Health Boards is not the sole responsibility of IPC Teams, but also falls to local teams, and is underpinned by organisational governance structures which ensure strategic oversight.

60. The audit process within NHS GGC has been recently updated in line with the National Monitoring Framework for Safe and Clean Care Audits. A bespoke, quality dashboard has been developed to provide an overview of other quality metrics which can impact staff's ability to undertake good IPC practice, such as staffing levels and patient acuity. The dashboard can show a breakdown of information by each individual clinical area. Senior Charge Nurses have access to the dashboard for monitoring quality within their area and are owners of their local improvement plans, a good example of the Health Board finding ways to strengthen responsibility for improvement at local levels.

61. Audits employing IPC Audit Tools (IPCAT) are undertaken using a collaborative approach to enable the appropriate individuals to take ownership of relevant actions and respond accordingly. Facilities and Estates teams are involved in audit processes in some areas, but there is no standard specifying who should be involved in the audit process at local level. A Combined Care Assurance Audit tool is currently being developed, which is expected to further strengthen collaborative working. NHS GGC reported that the IPCAT audit report and action plan are shared with ward staff, and discussed during ward huddles

62. IPCAT audits reflect a point in time and give a snapshot of IPC policy. The audit alone does not improve compliance – this must be achieved through a change in behaviours, adaptations to practice or processes and, where required, repairs/alterations to the built environment. Investigatory management beyond the immediate correction/action is essential if sustained change is to be achieved. Action plans arising from IPC need to use a quality improvement approach with local teams reviewing current systems and processes and agreeing, testing and implementing change ideas with improvement progress regularly assessed via local data collection.

63. It is not evident from either the IPCAT strategy or discussion with the IPC Team how local improvement is measured other than by undertaking a re-audit at set intervals based on the RAG status. The use of audits to drive improvement does not appear to be fully embedded in the relevant action plans, suggesting that there is a disconnect between the process of audit and follow up and the wider goals of improvement those processes should be supporting.

Approach to Surveillance

64. Surveillance is crucial in order to gather intelligence to identify HAIs and outbreak clusters, and facilitate rapid action to address them. National guidance sets out a requirement that organisations have a surveillance system to ensure a rapid response to HAI.

65. NHS GGC uses the IPC clinical surveillance platform, ICNet, to record surveillance data. ICNet is designed to enable a comprehensive approach to clinical surveillance, outbreak management and anti-microbial stewardship, and is customisable to the specific requirement of the user. Having used the system for a number of years, it appears that the system is effective in NHS GGC. The IPC Team in NHS GGC includes data analysts, who support data collation and outputs of surveillance enabling the Infection Control Nurses (ICNs) to focus on their clinical remit.

66. During the Peer Review, issues were raised about how regularly the triggers and organisms in ICNet system are updated regularly. For example, Appendix 13 of the NIPCM^[10] is a nationally-agreed minimum list of alert organism/conditions with the purpose of alerting Health Board IPC Teams and Health Protection (HP) Teams of occurrences which may require further investigation. Unless otherwise stated, a single case would require an IPC or HP Team review to advise that the correct IPC measures were in place to reduce transmission risk. Typically, two or more linked cases should trigger further investigations into a possible outbreak. The list provided in Appendix 13 of the NIPCM is not exhaustive and specialist units – such as bone marrow transplant or cystic fibrosis – will also be guided by local policy regarding other alert organisms pertinent to these areas.

67. The Peer Review team understood that despite previous infection outbreaks within NHS GGC, the only additional environmental alert gram-negative organisms added to their ICNet system (other than those within Appendix 13) were C.pauculus and Cryptococcus. This meant that the IPC Team had been purely reliant on laboratory surveillance alerting them to the presence of other environmental gram-negative isolates within patient specimens. Given the history of outbreaks, the diversity of environmental organisms seen and the rare nature of some of the organisms, a more pro-active approach to surveillance would have given a more systemic early-warning system given the recurrence of infections.

68. HPS/NSS conducted an 'External peer review of NHSGG&C processes (infection surveillance) related to Appendix 13 of the National Infection and Control Manual' in January 2018 (at the IPC Team's request), which found that:

"the processes around response to MRSA, SAB and C difficile were highly developed and extremely thorough. However, the processes for response to some of the other infectious threats highlighted in Appendix 13 are less well developed and further consideration needs to be given as to how to ensure consistent and equitable response to all of these infectious threats by the local team."

The Oversight Board Peer Review suggests that this further consideration is still required.

Use of Healthcare Infection Incident Assessment Tools

69. The NIPCM sets out the requirements for NHS Boards to assess all healthcare infection incidents using the HIIAT. An early and effective response to an actual or potential healthcare infection incident or outbreak is crucial. The local Health Board's IPC and HP Team should be aware of, and refer to, the national minimum list of alert organisms/conditions set out in Appendix 13 of the NIPCM. Within hospital settings the IPC Team normally take the lead in investigating and managing any incidents with support from the HP Team. Every healthcare infection incident in any healthcare setting should be assessed using the HIIAT.

70. In reviewing the HIIATs reported to ARHAI Scotland (formerly part of HPS), particular attention was given by the review team to 'green'-rated incidents. Incidents reported as 'green' have been provided to HPS/ARHAI Scotland 'for information only' with no escalation required to the Scottish Government. These are all reviewed by a Senior Infection Control Nurse within ARHAI Scotland and further information has been sought from the reporting Health Board where the assessment and scoring of the incident appears inconsistent with the HIIAT tool guidance.

71. A number of the 'green' incidents reported by NHS GGC over the period had been challenged by HPS/ARHAI Scotland. There were questions raised about whether the 'green' ratings were appropriate and how the recurrence of environmental infections within the QEUH site had been factored into the rating. HIIAT assessments rely on individual review and judgements that are necessarily subjective. Indeed, the ARHAI Scotland review of QEUH HIIATs for the Oversight Board noted some variation between different assessments across all Health Boards. But with respect to NHS GGC, several HIIAT assessments did not seem to take sufficient account of previous incidents within the same hospital site. Assessment should not focus exclusively on individual occasions of infection, but take into consideration wider backdrop issues. Indeed, there had been cases when HPS/ARHAI Scotland requested the Health Board to reassess an incident, taking into account previous incidents, although NHS GGC often chose not to change its initial assessment.

72. ARHAI Scotland concluded that there is a need for national as well as local learning here. Context should be a key element in the application of this alert system, a recognition that incidents may assume a different significance when considered in light of any potential pattern of infection incidents faced by the Health Board and the possibility of links to the environment. Opportunities for intervention by the Health Board as a consequence of taking a wider view of infections may have been lost. As a result, there is need for a deeper investigation of how NHS GGC continues to rate its infection incidents in the QEUH going forward.

Approach to Improvement

73. A systematic approach to healthcare improvement and better IPC have been ever more closely linked in recent years. Indeed, the Scottish Patient Safety Programme, which has embedded a more comprehensive improvement ethos across NHS Scotland, was in large part a response to the implications of the Vale of Leven Inquiry. Health Boards should not only be fulfilling current operational duties with respect to IPC, but ensuring that actions are taken to support improvements in their approach.

74. Improvement is explicitly highlighted within the overarching IPC guidance in NHS GGC, but it is not a responsibility lodged in a single part of the organisation. As set out in the Health Board's own Governance and Quality Assurance Framework for IPC Services, the IPC Team is responsible for, amongst other things:

• ensuring advice on IPC is available;
• in liaison with other relevant staff preparing, reviewing and updating evidence-based policies and guidelines in line with relevant UK Department of Health notifications and/or guidelines, when available and applicable;
• ensuring the provision of appropriate education to all grades of staff working within the scope of the policy; and
• providing specialist advice to key committees, groups, departments or individual staff members in relation to IPC practice.

Consequently, the role of the IPC Team is not standalone, but part of the wider conduct of Health Board responsibilities, recognising that IPC can only be successfully carried out when it is embedded across NHS GGC and driven by a commitment to continuous improvement. The IPC Team has the central role in this process of mainstreaming – in effect, ensuring that IPC is not just the responsibility of the IPC Team.

75. Based on international work undertaken between the Institute of Healthcare Improvement in Boston and Healthcare Improvement Scotland, the Model for Improvement (MFI) is the most widely used improvement methodology used within healthcare in Scotland. The MFI asks three questions:

• what are we trying to accomplish (aim);
• how will we know that change has made an improvement (data collection); and
• what change can we make that will result in improvement (change ideas).

These can be laid out in terms of the improvement journey which outlines the stages on an improvement initiative or project. Successful change occurs when there is commitment, a sense of urgency or momentum (for example, higher infection rates), stakeholder engagement, openness and a clear vision that is communicated well. Involvement of those people in the system is vital to success as they understand the system better than anyone else as development of change ideas will come from their experience of the local practice. These changes require: small-scale, iterative testing ('plan, do, study act', or PDSA); refining and adapting these using the knowledge from each successive test and all the time gathering data to indicate whether change is resulting in improvement. Once the local team is confident that the process change is improving outcome (and this is clearly monitored and verified), then and only then, should wholesale local implementation commence.

76. As an agent of Board-wide improvement change, there are excellent examples of this kind of change in NHS GGC. One good example is the quality improvement project to reduce the central line-associated bloodstream infection (CLABSI) rate in the paediatric haemato-oncology population.

Quality improvement to reduce the CLABSI rate in paediatric haemato-oncology

From 2017, the Health Board undertook an exercise to improve infection rates and infection prevention behavior in the paediatric haemato-oncology unit. Surveillance data showed fluctuations in CLABSI rates in the Schiehallion Unit. Before de-canting to QEUH wards in September 2018, Ward 2A in the RHC was a haemato-oncology unit and housed the National Bone Marrow Transplant Unit as well as the Teenage Cancer Trust. Ward 2B was the daycare component of Ward 2A. Staff began researching evidence on the topic and found benchmarking guidance from the Cincinnati Children's Hospital in the US. This led to a Quality Improvement Project using the Model for Improvement and a focused test of change to reduce the incidence of CLABSI in the haemato oncology population. Elements of the project included introducing unified line insertion protocols as well as staff and family education around line care and maintenance.

The methodology was applied with a specific, measurable target: to reduce the number of CLABSIs in Schiehallion Unit patients to 1 per 1,000 total line-days. This was supported by a clearly-defined driver diagram with primary and secondary drivers defined by tailored measurements, and a set of successful outcomes.

Key outcomes

• An issue identified and acted on using QI methodology locally led with support and reporting through Health Board structures
• CLABSI rate reduced and stabilised: from a rate of 6.33 in June 2017 to just over 1 by the start of 2020
• Almost 80 percent reduction from peak phase and just under 60 percent reduction from baseline
• Benchmarking 'like-for-like data' challenging, however, best in country when compared to similar paediatric units
• Going forward – focused on improvement of services continuous improvement, shared learning

77. Across NHS GGC as a whole, there are other instances of IPC focusing on improvement. For example, with respect to gram-positive infections, there is notable performance against national expectations. The Clinical Outcomes Review commissioned by the Chief Executive as part of a trio of stocktaking reports on the QEUH, and which reported to the Board at its meeting in October 2019, concluded: "both internal and external review of available data indicates the QEUH and the RHC are not outliers in terms of rates of Healthcare Associated Infection (HAI) or practice."^[11] Timeous and effective action across NHS GGC was also evident in responding to individual infection issues, as the Oversight Board saw in the case of the 2019 Stenotrophomonas maltophilia outbreak at the Royal Alexandria Hospital in Paisley.

2019 infection outbreak at the Royal Alexandria Hospital

A number of instances of Stenotrophomonas maltophilia were identified at the Royal Alexandra Hospital in Paisley in early 2019. Infections in previously healthy patients are typically unusual. Nosocomial infections (ie. originating in a hospital) has been increasingly recognised, and usually only occur in those with significantly-impaired immune defences, such as severely immuno-compromised patients. This can cause bloodstream, respiratory, urinary and surgical-site infections. Risk factors pre-disposing a hospitalised patient towards infection include prior exposure to anti-microbials (especially broad-spectrum antibiotics), mechanical ventilation and prolonged hospitalisation. It may also affect the lungs of patients with cystic fibrosis.

S. maltophilia is resistant to many antibiotic classes. This means that treatment options are relatively limited. However, most strains remain susceptible to co-trimoxazole which is regarded as the drug of choice for treating infections. In January 2019, the IPC Team was informed of three instances related to Stenotrophomonas, which led to an IMT being convened by the end of the month. The Board was updated via the Healthcare Associated Infection Reporting Template (HAIRT) in February, and further updates were provided to the Care and Clinical Governance Committee, the Board Infection Control Committee and the Acute Infection Control Committee in March.

When the outbreak took place, a robust structure was in place which meant the incidents were managed timely and effectively at all stages. The key outcomes were:

• timely management of the incident and establishment of multidisciplinary team improves outcomes and communication;
• strict adherence to IPC procedures to reduce the risk of transmission of infection;
• communication with patients and families was pursued as a central part of incident management and managed by the clinical team with support from the IMT;
• a recognition that roles and responsibilities in environmental sampling needed to be clarified; and
• information flow from Reference labs needed to be streamlined.

78. What was notable in the above incident was the highlighting of the 'lessons learned' and the determination that relevant improvements were made in the local IPC Team. The Oversight Board saw abundant evidence of the hardworking and diligent nature of the staff in this area, with commitments to improving outcomes and ensuring patient safety and better care.

79. It is clear that the Health Board could learn from the experience of its infection incidents and adjust accordingly its approach, structures and actions, especially from 2018 onward. This was notable in several key developments (as discussed in more detail in the Final Report): the establishment and active work of a Technical Water Group to provide a targeted response to the set of 2018 infections; the updating of NHS GGC's Water Safety Policy in 2018; and the development of a single IPC Assurance and Accountability Framework from a set of separate documents.

80. Nevertheless, these instances did not appear to be part of a more systematic approach to learning led by the IPC Team. Apart from a handful of commendable but seemingly isolated examples, there did not appear to be a sustained approach to IPC improvement across the Health Board. It was a recurring theme of the issues examined by the Peer Review and the approach taken to HIIATs discussed above.

81. For example, as part of the work of the Peer Review, the investigating team asked NHS GGC for examples of how local surveillance data was used to inform quality improvement work. The IPC Team has been involved in much of the quality improvement work that was cited, including development of Peripheral Venous Cannula (PVC) care plans which supported frontline staff in undertaking the correct, evidenced-based care of PVCs. This work was led by the IPC Team without apparent implementation of the model for improvement – consequently, ownership of the required improvement was not taken up by the clinical teams or services. There was no evidence of a structured use of quality improvement methodology and a focus on outcomes. Importantly, it was not evident that the relevant local teams were leading this work. Put simply, improvement work was too often siloed within the IPC Team without sufficient mainstreaming across other teams.

82. Similarly, the role of the IPC Team in producing guidance and policy raised concerns. In addition to the individual standard infection control and transmission-based precautions, there were a number of other SOPs that seemed to have been produced principally by the IPC Team. One example was a SOP Team for the insertion and maintenance of urethral urinary catheters – as catheter insertion and maintenance is typically the role of local bowel and bladder teams, the role of the IPC Team in leading the drafting of this SOP was confusing. Whilst the IPC Team should support and advise this work, it is inappropriate for them to lead. Indeed, it was not clear whether the local bowel and bladder reference group was involved in this work.

83. This does not reflect an IPC service which is integrated and collaborative. It appears to be one that provides a standalone service rather than advises and works towards the mainstreaming of IPC improvement. The ethos of improvement should be to work together across existing professional and organisational boundaries when the opportunity to find better ways of delivering shared outcomes can be achieved, and to focus on outcomes. That approach was inherent in the CLABSI work described above and should be more systematically pursued across the IPC Team.

84. In this context, the new IPC improvement collaborative being established through work led by Professor Angela Wallace is welcomed. This collaborative should encompass explicit learning from the QEUH infection incidents, not least with respect to handling gram-negative bacteria infections and working against the background of a potentially-compromised building. The recent refocusing of Executive responsibilities within NHS GGC around a 'Gold Command' structure – led by the Health Board's Chief Executive – and the creation of a new strand of transformation activity on 'Better Safe, Clean Clinical Environment' under the leadership of the Interim Deputy Director for IPC, the Chief Operating Officer and the Director of Facilities and Estates is an opportunity to drive such improvement. If this strand of work is rooted in a comprehensive review of processes and performance issues for IPC, informed by the findings and recommendations made through the Oversight Board and other review processes, this could prove a powerful vehicle for delivering a change in approach to improvement.

Remaining Work

85. As already stated, this Interim Report does not cover all aspects of the Oversight Board's review of IPC. Several critical aspects are still being examined and will feature in the Final Report, including:

• Responsiveness: how responsive were IPC functions in identifying and taking appropriate action with regards to the children and young people in these infection incidents – not just in terms of addressing the incidents themselves and learning quickly from the experience, but also the efforts to understand the source of infections and take appropriate preventative measures;
• Joint working in IPC: effective IPC within a Health Board depends not just on the strength of the IPC Team, but how that Team link with other key functions across the organisation – this will review how well cooperative working to support IPC was evident in the QEUH, particularly between key staff with a responsibility for undertaking IPC such as Facilities and Estates and microbiologists; and
• Leadership: the strength of the current structure of responsibilities for the IPC Team in NHS GGC, and whether those divisions of responsibilities are best suited in these circumstances.

86. While recommendations on the aspects of IPC discussed here are made at the end of this Interim Report, the full conclusions of the Oversight Board on IPC will be made in the Final Report. This will include assurance on IPC within NHS GGC in the context of the infection incidents in the QEUH.