Publication - Independent report

Queen Elizabeth University Hospital: case note review - overview report

Published: 22 Mar 2021

This overview report examines the incidence and impact of qualifying episodes of infection in paediatric haemato-oncology patients cared for at the Queen Elizabeth University Hospital and the Royal Hospital for Children from 2015 to 2019 and the potential link to the hospital environment.

Queen Elizabeth University Hospital: case note review - overview report
Footnotes

Footnotes

1 Review of NHSGG&C Paediatric Haemato-oncology Data. Health Protection Scotland. November 2019 https://www.hps.scot.nhs.uk/web-resources-container/review-of-nhsggc-paediatric-haemato-oncology-data/

2 Both the February 2019 HPS report and the 2020 Independent Review report state that this child was a patient on Ward 2A, in which case he/she would have been included in our Review. This was not the case and ARHAI have since confirmed that this child was not a patient on Ward 2A.

3 https://www.hps.scot.nhs.uk/web-resources-container/summary-of-incident-and-findings-of-the-nhs-greater-glasgow-and-clyde-queen-elizabeth-university-hospitalroyal-hospital-for-children-water-contamination-incident-and-recommendations-for-nhsscotland/

4 Pizzo PA. Management of Patients With Fever and Neutropenia Through the Arc of Time: A Narrative Review. Ann Intern Med. 2019 Mar 19;170(6):389-397. doi: 10.7326/M18-3192. Epub 2019 Mar 12. PMID: 30856657.

5 Aljabari S, Balch A, Larsen GY et al. Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer. J Pediatr Intensive Care. 2019; 8(3): 122-129. doi: 10.1055/s-0038-1676658

6 Levene I, Castagnola E, Haeusler G. Antibiotic-resistant Gram-negative Blood Stream Infections in Children with Cancer: A Review of Epidemiology, Risk Factors, and Outcome. The Paediatric Infectious Disease Journal: 2018; 37(5): 495-498. doi: 10.1097/INF.0000000000001938

7 Hann I et al. "A comparison of outcome from febrile neutropenic episodes in children compared with adults". British Journal of Haematology, vol. 99, no. 3-I, December 1997, pp. 580-588

8 Asturias EJ, Corral JE, Quezada J et al. Evaluation of six risk factors for the development of bacteraemia in children with cancer and febrile neutropenia. Curr Oncol. 2010; 17(2): 59-63. doi: 10.3747/co.v17i2.453

9 Al-Mulla NA, Taj-Aldeen SJ, Shafie S E et al. Bacterial blood stream infections and antimicrobial susceptibility pattern in pediatric hematology/oncology patients after anticancer chemotherapy. Infect Drug Resist. 2014; 7: 289-299 doi:10.2147/IDR.S70486

10 Duncan C, Chisholm JC, Freeman S et al. A prospective study of admissions for febrile neutropenia in secondary paediatric units in South East England. Pediatr Blood Cancer. 2007; 49(5):678-81.doi: 10.1002/pbc.21041.

11 Weiss SL, Fitzgerald JC, Pappachan J et al. Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study Investigators and Paediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Global epidemiology of paediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med. 2015;191(10):1147-57. doi: 10.1164/rccm.201412-2323OC.

12 Fiser RT, West NK, Bush AJ et al. Outcome of severe sepsis in pediatric oncology patients Pediatr Crit Care Med. 2005;6(5):531-6. doi: 10.1097/01.pcc.0000165560.90814.59.

13 Akinboyo IC, Young RR, Spees LP, Heston SM, Smith MJ, Chang YC, et al. Microbiology and Risk Factors for Hospital-Associated Blood stream Infections Among Pediatric Hematopoietic Stem Cell Transplant Recipients. Open Forum Infect Dis. 2020;7(4):ofaa093

14 Simon A, Fleischhack G, Hasan C et al. Surveillance for nosocomial and central line‐related infections among pediatric hematology‐oncology patients. Infection Control and Hospital Epidemiology 2000;21:592‐6

15 Youssef A, Hafez H, Madney Y et al. Incidence, risk factors, and outcome of blood stream infections during the first 100 days post-pediatric allogenic and autologous hematopoietic stem cell transplantations. Pediatr Transplant. 2020; 24(1):e13610

16 Haeusler GM, Levene I. Question 2: What are the risk factors for antibiotic resistant Gram-negative bacteraemia in children with cancer? Archives of Disease in Childhood 2015;100:895-898

17 Lehrnbecher T, Fisher BT, Phillips B, Alexander S, Ammann RA, Beauchemin M, Carlesse F, Castagnola E, Davis BL, Dupuis LL, Egan G, Groll AH, Haeusler GM, Santolaya M, Steinbach WJ, van de Wetering M, Wolf J, Cabral S, Robinson PD, Sung L. Guideline for Antibacterial Prophylaxis Administration in Pediatric Cancer and Hematopoietic Stem Cell Transplantation. Clin Infect Dis. 2020;71(1):226–36. https://doi.org/10.1093/cid/ciz1082.

18 We have only included infections that arose after attendance/ admission to the new QEUH/RHC site.

19 We will issue individual reports to all families

20 This involved staff from National ARHAI Scotland, NSS

21 This was the initial cohort – see Chapter 4, section 4.1 for detail of subsequent exclusions

22 See Appendix D for the full dataset

23 See section 3.4.3

24 These letters were sent on 4th March 2020. In fact, specific engagement with families was (and remained) the remit of Professor Craig White (this text was that of the original Terms of Reference and in this respect does not reflect the agreed position of Professor White).

25 This implies both the clinical and epidemiological team. See the detail of our approach in section 3.6

26 This was an ambitious target, declared before the full complexity of the task and the impact of the COVID-19 pandemic were apparent. See section 3.1 for detail of the constraints on the progress of the Review

27 Case Note Review. Paediatric Haemato-Oncology Patients, Royal Hospital for Children NHS Greater Glasgow and Clyde. Epidemiology and Clinical Outcomes Protocol; April 2020 v1.0

28 Review of NHSGG&C Paediatric Haemato-Oncology Data. Health Protection Scotland; November 2019. https://www.hps.scot.nhs.uk/web-resources-container/review-of-nhsggc-paediatric-haemato-oncology-data/

29 Expert Panel Dataset v1.0. 17.04.20

30 v 3.5.1 (2018-07-02). The R Foundation for Statistical Computing

31 The Health Foundation. Evidence scan: Levels of Harm 2011 [Available from: www.health.org.uk/publications/levels-of-harm/.

32 Healthcare Improvement Scotland. Learning from adverse events through reporting and review. A national framework for Scotland: 2019 http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/management_of_adverse_events/national_framework.aspx.

33 Root cause analysis offers a structured approach to the investigation of patient safety incidents and facilitate organisational learning

34 Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011;30(4):581-9. doi: 10.1377/hlthaff.2011.0190 [published Online First: 2011/04/08]

35 Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995;21(10):541-8. doi: 10.1016/s1070-3241(16)30180-8 [published Online First: 1995/10/01]

36 Solevåg AL, Nakstad B. Utility of a Paediatric Trigger Tool in a Norwegian department of paediatric and adolescent medicine. BMJ Open 2014;4(5):e005011. doi: 10.1136/bmjopen-2014-005011 [published Online First: 2014/05/21

37 Sharek PJ, Parry G, Goldmann D, et al. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Health Serv Res 2011;46(2):654-78. doi: 10.1111/j.1475-6773.2010.01156.x [published Online First: 2010/08/21]

38 Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. BMJ Open 2014;4(7):e005066. doi: 10.1136/bmjopen-2014-005066 [published Online First: 2014/07/06]

39 Matlow AG, Cronin CMG, Flintoft V, et al. Description of the development and validation of the Canadian Paediatric Trigger Tool. BMJ quality & safety 2011;20(5):416-23.

40 Details are provided in a separate, more detailed, report of the use of the PTT and its findings requested by the Chief Nursing Officer.

41 https://www.nccmerp.org

42 National Infection Prevention and Control Manual. NHSScotland

43 Principles of Epidemiology in Public Health Practice, Third Edition: An Introduction to Applied Epidemiology and Biostatistics. https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section6.html

44 RHC Case Note Review – Defining the impact of the infection episode v1.0. 27.8.20

45 Healthcare Improvement Scotland. Learning from adverse events through reporting and review: A national framework for Scotland. December 2019.

46 The terminology was subsequently adjusted by the Panel to match that used by the NHS Scotland Risk Assessment Matrix (Negligible, Minor, Moderate, Major, Extreme)

47 The description used here of Grade 4 (Major) impact is that used for the Patient Experience descriptor (rather than the Injury descriptor) in Healthcare Improvement Scotland. Learning from adverse events through reporting and review. A national framework for Scotland 2019.

48 Children and Young People with Cancer in Scotland 2009-2018. Public Health Scotland 2020. https://beta.isdscotland.org/find-publications-and-data/conditions-and-diseases/cancer/children-and-young-people-with-cancer-in-scotland/

49 Although data collection limits were set from 15.5.2015 to 31.12.2019, we recognise that patient transfer did not take place until June and no infections were included before that date. In fact, the first infection included in the Review was identified on 21.10.2015.

50 Queen Elizabeth University Hospital Review Report. Scottish Government. June 2020

51 Water Management Issues Technical Review. NHS Greater Glasgow and Clyde – Queen Elizabeth University Hospital and Royal Hospital for Children. Health Facilities Scotland. March 2019

52 Issues summarised in: Potential infection control risks associated with chilled beam technology: experience from a UK hospital. T Inkster, C Peters, H Soulsby. J Hosp Inf, 2020;106:613-616

53 Scottish Hospitals Inquiry. https://www.hospitalsinquiry.scot

54 Summary of the Incident and Findings of the NHS Greater Glasgow and Clyde: Queen Elizabeth University Hospital/ Royal Hospital for Children water contamination incident and recommendations for NHSScotland. Health protection Scotland. December 2018

55 SBAR – Ward 6A environment. Microbiology dept QEUH. 26/8/2019.

56 Healthcare Associated Infection – System for Controlling Risk in the Built Environment: a system used to identify, manage and record built environment infection control.

57 SHFN 30 Part B: HAI-SCRIBE Implementation strategy and assessment process. Health Facilities Scotland 2014.

58 National Infection Prevention and Control Manual. NHSScotland http://www.nipcm.scot.nhs.uk

59 A National Monitoring Framework to Support Safe and Clean Care Audit Programmes . An Organisational Approach to Prevention of Infection Auditing. NHS National Services Scotland 2018. https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2678/documents/1_national-monitoring-framework.pdf

60 NHSScotland National Cleaning Compliance Report Domestic and Estates Cleaning Services Performance 2015/2016. Health Facilities Scotland 2016. https://nhsnss.org/media/4966/1479909664-2015-16-cleaning-monitoring-report-quarter-4-v10-published.pdf

61https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/140105/Health_Technical_Memorandum_04-01_Addendum.pdf

62 https://hpspubsrepo.blob.core.windows.net/hps-website/nss/1989/documents/3_psuedomonas-water-testing-v1.0.pdf

63 https://www.hps.scot.nhs.uk/web-resources-container/guidance-for-neonatal-units-nnus-levels-1-2-3-adult-and-paediatric-intensive-care-units-icus-in-scotland-to-minimise-the-risk-of-pseudomonas-aeruginosa-infection-from-water/

64 Water Management Issues Technical Review. NHS Greater Glasgow and Clyde – Queen Elizabeth University Hospital and Royal Hospital for Children. Health Facilities Scotland. March 2019

65 Queen Elizabeth University Hospital Review Report. Scottish Government. June 2020

66 Although NHS GGC told us that they had been able to link one of the three cases of Mycobacterium chelonae in our Review to the environment (see also section 8.3.1), we have not seen the confirmatory data and, without which, we have not classified the case as Definite.

67 Of the total of 118 episodes evaluated in the Review, 3 were excluded from the count of bacteraemias: one involved sepsis with Pseudomonas aeruginosa which was isolated from other sites but not from blood cultures; a second involved a culture proven disseminated infection with Mycobacterium chelonae but without positive blood cultures; and a third patient was excluded as although this patient had a gram negative environmental bacteraemia, this was detected and managed at another hospital after previously attending NHS GGC.

68 Category I events are those that may have contributed to or resulted in permanent harm, for example unexpected death, intervention required to sustain life, severe financial loss (£>1m), ongoing national adverse publicity. These are likely to be graded as major or extreme impact on NHSScotland risk assessment matrix, or Category G, H or I on National Coordinating Council for Medical Error Reporting and Prevention (NCC MERP) index.

69 Healthcare Improvement Scotland. Learning from adverse events through reporting and review. A national framework for Scotland: December 2019 2019: http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/management_of_adverse_events/national_framework.aspx

70 12 PICU admissions for infection related AE; 4 for AE unrelated to infection; and 3 with PICU admissions that were not classified as AE.

71 Category II events are those that may have contributed to or resulted in temporary harm, for example initial or prolonged treatment, intervention or monitoring required, temporary loss of service, significant financial loss, adverse local publicity. These are likely to be graded as minor or moderate impact on NHSScotland risk assessment matrix, or Category E or F on NCC MERP index

72 Category III events are those that had the potential to cause harm but no harm occurred, for example near miss events (by either chance or intervention) or low impact events where an error occurred, but no harm resulted. These are likely to be graded as minor or negligible on NHSScotland risk matrix or Category A, B, C or D on NCC MERP index

73 DMA was the private contractor employed by NHS GGC to undertake water sampling

74 Healthcare Associated Infection – System for Controlling Risk in the Built Environment: a system used to identify, manage and record built environment infection control.

75 The PAG was added to the process as part of the update to the NHS GGC Outbreak SOP in 2019

76 National Infection Prevention and Control Manual. NHSScotland http://www.nipcm.scot.nhs.uk

77 The Vale of Leven Hospital Inquiry Report. November 2014.

78 HAI-related incidents, outbreak/incidents and data exceedance: Assessment, and reporting requirements and communication expectations. ACNO February 2019.

79 The definitions used in the Protocol agreed for the Case Note Review were: Hospital associated infection (HAI) – positive blood culture in a patient who has been hospitalised for at least 48 hours and Healthcare associated infection (HCAI) – positive blood culture in patient within 48 hours of admission but who has had specified healthcare contact or intervention in the prior 30 days. In the event, we did not find this distinction useful in our review.

80 Note that the numbers of Klebsiella isolates exceed the number of patients because some episodes were polymicrobial.

81 http://www.nipcm.scot.nhs.uk

82 Dates and some detail of the infections have been omitted from this quote to protect patient identity

83 Review of NHS GGC Paediatric Haemato-oncology data. Health Protection Scotland. October 2019

84 This patient was not included in our review

85 Records were not reviewed for one patient as the bacteraemia was identified and managed at another hospital after day case attendance at NHS GGC.

86 Children’s Early Warning Score. This identifies paediatric patients at risk for clinical deterioration.

87 A ‘Bundle’ is a structured way of improving processes of care and patient outcomes; in this context in relation to central and peripheral venous catheters

88 Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. BMJ Open 2014;4(7):e005066. doi: 10.1136/bmjopen-2014-005066 [published Online First: 2014/07/06]

89 https://www.nccmerp.org

90 Healthcare Improvement Scotland. Scottish Mortality and Morbidity Programme [Available from: http://www.healthcareimprovementscotland.org/our_work/patient_safety/scottish_mortality__morbidity.aspx.

91 Royal College of Paediatrics and Child Health. Paediatric ST4 Recruitment 2020 – R2R Self-assessment Framework & Guidance [Available from: https://www.rcpch.ac.uk/sites/default/files/2020-07/st4_recruitment_2020_round_2_readvert_self-assessment_framework_0.pdf

92 Royal College of Paediatrics and Child Health. Paediatric ST1 Recruitment 2020-2021 Application Scoring Framework & Guidance [Available from: https://www.rcpch.ac.uk/sites/default/files/2020-11/ST1%20Application%20Form%20Scoring%20Framework%20v.3b%20JAC%20291020_0.pdf

93 Three patients were excluded because they did not have central line associated bacteraemia treated in GGC (two had no central line in place during the episode of infection, and one was not an inpatient in GGC during the infection episode).

94 Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49(1):1-45. doi: 10.1086/599376

95 2020 exceptional surveillance of neutropenic sepsis: prevention and management in people with cancer (NICE guideline CG151)

96 Lehrnbecher T, Fisher BT, Phillips B, Alexander S, Ammann RA, Beauchemin M, Carlesse F, Castagnola E, Davis BL, Dupuis LL, Egan G, Groll AH, Haeusler GM, Santolaya M, Steinbach WJ, van de Wetering M, Wolf J, Cabral S, Robinson PD, Sung L. Guideline for Antibacterial Prophylaxis Administration in Pediatric Cancer and Hematopoietic Stem Cell Transplantation. Clin Infect Dis. 2020;71(1):226–36. https://doi.org/10.1093/cid/ciz1082.

97 Shared care is the arrangement by which the specialist haematology oncology centre (in this case NHS GGC) continues to direct overall patient management but works with a general hospital local the patient’s home to deliver aspects of care, for example, less complex courses of chemotherapy, blood product transfusion, nutritional support.

98 The MSN is charged with delivering the Scottish Governemnt’s vison for cancer services for children and young people – to attain the best possible outcomes; ensure access to appropriate, safe and sustainable specialist services as locally as possible; and that pathways of care are as equitable as possible across the country. https://www.youngcancer.scot.nhs.uk/managed-service-network/about-us/about-the-network


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