National Standards for the Prevention and Control of Healthcare Associated Infections (NSPCHCAI) Monitoring Programme
QUALITY IMPROVEMENT ACTION PLAN.
Report of inspections at Letterkenny University Hospital, Co Donegal :
18th June 2015= Medical 2 Ward & Orthopaedic Ward.
23rd July 2015 = Re-Inspection of Medical 2 Ward & Orthopaedic Ward, + Paediatric Ward, ICU, Surgical 2 Ward , Haematology/Oncology
In -Patient Ward located on Medical 4 & Operating Theatres.
Number Immediate High Risk
1
Environmental Hygiene
1.1
Poor standards of environmental
hygiene observed in all areas inspected
and re-inspected.
There was no significant improvement
in the overall standard of environmental
hygiene in the wards visited at the time
1
LGH Q&R Dept. QIP/EE/October 15/version 7
Action
1. Robust review of tools,
resources, compliance and
processes was undertaken.
Person(s) Responsible
Completion
Date
Review
Date/
Outcome
Measures
GM. DON&M, Clinical and
Associate Clinical Directors.
Facilities Manager, Domestic
Supervisors, IPCM,
ADON/SM’s, Q &S Manager
Commenced July
24th 2015
Environmental
Hygiene Audit
results.
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1.2
of re-inspection
Cleaning processes
Dust and grit under beds, on floor
edges, corners in all patient’s areas and
ancillary rooms inspected (Med 2,
Orthopaedics)
Same mop head was used for dust control
in all patient areas including isolation
rooms.
Insufficient mop heads available to
facilitate cleaning
1.3
HIQA found that areas had not been deep
cleaned since previous visit
1.4
Vacuum cleaning was not routinely
carried out and dust control mops were
coated in dust and fluff.
1.5
Heavy dust was visible on the majority
of ceiling ventilation grilles inspected
(Med 2)
1.6
Bathrooms.
Surfaces of sanitary ware, grab rails, tiles,
floors, shower screens, and accessories,
including toilet roll holders were not
cleaned to an acceptable standard
2
LGH Q&R Dept. QIP/EE/October 15/version 7
1. Review processes/ Develop
Standard Operating
Procedure’s x28
2. Procure microfiber mops
3. Refresher In-service training
for domestic staff on
infection prevention &
control
4. On the job Refresher SOP
training provided for
Domestic Staff.
1. Rolling weekly Deep Cleaning
schedule implemented.
Facilities Manager/Domestic
Supervisors
Daily check
IPCM/Team
Environmental
Hygiene Audit
results.
Biannual
training
Target 100%
Domestic Supervisors
Facilities Manager, Domestic
Supervisors and Team
Commenced
August 2015
1. Pilot organised in Medical 4
and Surgical 1 – A
comparative analysis of
vacuuming and microfiber
mops undertaken.
2. Option Appraisal being
colLated
Facilities Manager and Team
Infection Prevention and
Control team (IPCT)
November 13th
1. Immediate action-All grilles
cleaned.
2. Schedule for ongoing
cleaning and Maintenance.
1. Patient Environment Hygiene
Policy developed, is now on
consultation process and will
be ratified at MDT PPG
committee.
Facilities Manager, Domestic
Supervisors & Team
Completed
Maintenance Manager
Domestic supervisors
All Ward Managers, DON&M,
ADON/SM’s, All Department
Heads, Senior Management
Team
On going plan
For ratification at
MDTPPPG
Committee
3/12/2015
On going.
Environment
Hygiene Audit
27th
November
Recommendations
On Nov 27th
Environmental
Hygiene
Audits
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Environmental
Hygiene
Audits
Environmental
Hygiene
Audits
1.7
1.8
2
3
Cleaning storage facilities.
Dust and grit noted on cleaning trolley.
Surfaces in the areas used to store
cleaning equipment and supplies were
dusty, stained and cluttered.
Dust control mops were stored directly
on floors
Mop handles with attached mop heads
were stored over taps on the janitorial
sink.
Wet cloths and wet mop heads present
on cleaning trolleys.
Extraneous items were stored directly on
floor.
Hazardous consumables were not locked
away.
Personal Protective Equipment was not
used appropriately
1. Review processes/ SOP’s
2. Department specific Cleaning
Manual to be made available
in all areas. Store in ring
binders for all staff access.
3. Available on Q-Pulse
4. Refresher In -service staff
training.
5. Facilities Manager meeting
with “Safeguard” in relation
to the use of the Staff Access
Control System currently
used throughout the hospital
to secure hazardous
consumables.
Facilities Manager
Domestic supervisors and staff
CNM/CMM’s
Heads of Department
Facilities Manager
Meeting
November 30th
2015
1. Targeted retraining of
specific personnel Med 2
2. Reissue of Guideline for
Correct Use of Personal
Protective Equipment during
Clinical Work Practices.
Available on Q Pulse.
3. IPC Link Liaison nurse on
each ward/department
4. Next IPC Link Nurse
programme commencing
Nov 25th 2015 CNME
5. Posters/Visuals campaign
Infection Prevention Control
Team
Facilities Manager
Domestic Services
ADON/SM’s,
CNM’s/CMM’s
IPC Link Nurse Group
July 2015
Dec 2015
Sept 2015
Nov 25th 2015
Patient Equipment:
The overall standard of patient
LGH Q&R Dept. QIP/EE/October 15/version 7
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Environmental
Hygiene Audit
Hand Hygiene
Audits capture
inappropriate
use of gloves
Action plans
for noncompliance
equipment cleaning and maintenance
was unsatisfactory.
The authority did not see evidence during
July re-inspection that retraining in
relation to patient equipment hygiene
had been completed.
There is a lack of clear responsibility for
cleaning duties in relation to patient
equipment and workstation cleaning.
New cleaning checklists are basic,
contained little detail and did not indicate
who was specifically responsible for
cleaning.
Findings indicated that little improvement
had occurred in the management of
patient equipment between the 2015
inspections.
Dust on bedside storage and curtain rails
in patient areas inspected.
Visible staining observed on Patient chairs
and bed tables.
2.1
2.2
2.2.2
4
Visible Staining noted on equipment:
Sharps tray
Enteral feeding pumps,
Debris present on portable nebulisers.
Dust and fluff on wheels of commodes.
Dust on ECG machines,
Moving and handling hoists,
Cardiac monitor,
LGH Q&R Dept. QIP/EE/October 15/version 7
1. Definitive roles &
responsibilities
2. Revise / Develop SOP’s
3. Education Sessions for
Healthcare Assistants,
Domestic Services staff
Facilities Manager,
ADON/SM’s
Department Managers,
CNM’s /CMM’s
1. Urgent review of processes for
management and care of
patient equipment.
2. SOP’s x 28 developed
3. Clear responsibility outlined.
Facilities Manager,
Domestic Supervisors
CNM’s/CMM’s
1. Definitive roles &
responsibilities
2. Devise SOP
ADON/SM’s,
All Ward managers
1st Quarter 2016
On going
November 2015
Environmental
Hygiene
Audits
Dec 2015
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Environmental
Hygiene
Audits
2.2.3
Medical chart trolleys
IV trolleys
Sharps bins
Blood pressure cuffs
Commodes
Blood glucose monitor holder
Cleaning tagging system
Items of patient’s equipment had green
tags to indicate that they had been
cleaned but a number of these items had
not been effectively cleaned. Equipment
which had been labelled as clean on the
day of the inspection was dusty.
2.2.4
Workstation cleaning
There is a lack of clear responsibility for
cleaning duties in relation to workstation
cleaning. Dust noted on:
Computer keyboards,
Telephone receivers
Workstation surfaces.
2.3
Servicing of Bed pan washers not
performed at recommended intervals as
per manufacturers
2.4
Beds
5
LGH Q&R Dept. QIP/EE/October 15/version 7
1. Ward Managers to carry out
equipment cleanliness check
using visual observation and
ensuring compliance with the
existing tagging system
2. Develop an SOP to include
tagging system
CNM’S/CMM’s
Ongoing
Daily
1. To be included in SOP for
ward cleaning schedule
2. Definitive role and
responsibilities/ Mon-Fri 95pm/weekends/Out Of
Hours
3. Facilities Manager to develop
SOP to include equipment on
Corridor spaces with sub
sections with specific
responsibilities for each
discipline.
4. Public service agreement to
be discussed with Union
1. Service of equipment must
be logged
2. Plan in place to replace
Macerators.
Housekeeping Staff
Clerical Staff – Public Service
Agreement.
DONM to meet with union to
discuss cleaning responsibilities
DONM to liaise with the HCA’s
to ensure case note trolleys are
cleaned. As per talks with
IMPACT union – all ward clerks
are responsible for their own
working environment.
December 2015
Daily
Maintenance Manager
General Manager
December 2015
Annual
Service.
Facilities Manager
On going
On going
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The undercarriages of the beds inspected
were heavily soiled with sticky oily
residue and heavy dust.
Dust also noted on pull out shelves of
beds
The authority notes that the design of
these bed frames did not facilitate easy
access for effective cleaning
2.5
Mattresses:
6/8 mattresses inspected were
compromised with significant visible
staining inside covers. One was grossly
stained and malodorous, and cover was
visibly damaged
2.5.1
6
Mattress storage
Stained mattresses were stored with
clean equipment (Med 2)
LGH Q&R Dept. QIP/EE/October 15/version 7
1. SOP – Domestic
Services/HCA’s
2. Part of deep clean schedule
3. Bed Replacement Plan in
place
1. An audit of all mattresses in
the hospital completed.
Compromised mattresses have
been removed.
4. “Policy for the Management
and Replacement of Hospital
Mattresses” developed and
ratified by MDT PPPG
committee on the 6th August.
5. Co-ordinated approach to
purchasing requested by
finance department
6. Central mattresses store and
including replacement covers
7. Storage space identified
1. Dedicated storage area
2. Coordinated approach to the
management of mattress
replacement programme.
3. Scope into Purchasing versus
Rental of air mattresses.
Domestic Services
HCA’s
Nursing & Midwifery Staff
General Manager
Finance Manager
On going
On going
December 2015
On-going
Ward managers
ADON/SM’s
Finance Manager
Facilities Manager
Facilities Manager
ADON/SM, Medical Directorate
General Manager
Finance Manager
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3
Environmental auditing
There is a need for more oversight of
environmental hygiene by middle and
senior management
Independent monitoring of hygiene
audits was not evident.
There was no multi-disciplinary hygiene
audit team in the hospital. Little
assurance provided that the monitoring
of environmental hygiene was adequate.
3.1
1. Active sustained supervision
and support by Senior
Managers who undertake
Hygiene Audit x 3 times
monthly.
2. CNM and Domestic
Supervisors Audit Quarterly
3. Hygiene Service Action group
convened (HSAG)
4. Quality & Patient Safety
Advisory committee oversee
the process and progress
reports.
Senior Management Team
Commenced Sept
2015
CNM’s / CMM’s
and Domestic Supervisors
Environmental
Hygiene
Audits
HSAG Weekly
meetings
Monthly
Quality &
Patient Safety
3.1.2
Lack of local ownership relating to ward
cleanliness and awareness of hygiene
audit results
1. Team approach by ward
managers and domestic
services staff
All ward/unit managers
Domestic Supervisors
Oct 2015
Weekly
3.2
The schedule for environmental auditing
was not adhered to.
Records of audits completed failed to
follow-up on areas which received poor
compliance and re-audits were not
carried out at the time of re-inspection.
1. Scheduled Audit Plan has
been devised and
implemented.
2. Actions plans developed and
re audits planned
3. Wards falling below standard
are addressed by the
Hygiene Services Action
Group.
4. Audit results reported to the
Clinical Nurse managers,
Domestic Staff.
ADON/SM’s
Facilities Manager
Hygiene Services Action Group
Quality &Patient Safety
committee
On going
Review
Weekly HSAG
7
LGH Q&R Dept. QIP/EE/October 15/version 7
Monthly
Quality &
Patient Safety.
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5.
3.3
There were deficiencies in the recording
of improvement actions and closing out
of issues highlighted through
environmental audits.
1.
2.
3.
4
Infrastructure and Maintenance
It is imperative that the resources
required to facilitate the
implementation of a proactive
preventative maintenance programme
are allocated and protected to achieve
and sustain improvements within the
facility.
4.1
Inspectors observed ward wide issues
8
LGH Q&R Dept. QIP/EE/October 15/version 7
Quality & Patient Safety
Committee monthly.
Summary of audit reports are
submitted to the HEB.
Action Plans are developed
and implemented after each
Audit.
Each Action Plan has a
proposed completion date
Each proposed completion
date must have an actual
completed date.
1. Budget Plan
All ward managers
Domestic Supervisors
Maintenance
ADON/SM’s
Heads of Departments
Hygiene Services Action Group
On going
Quarterly
Maintenance Manager
In progress
On going
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5
related to maintenance.
Surfaces, finishes, flooring, some
furnishings in patient’s rooms including
windows, wall paintwork, woodwork,
wood finishes were worn, and poorly
maintained and as such did not
facilitate effective cleaning.
Deficits with respect to maintenance on
the Orthopaedic Unit were identified.
2. A specific planned
refurbishment programme
for Orthopaedics and
Surgical 1 implemented.
3. Hospital wide
refurbishment plan
ongoing until January
2016.
4. 2016 Refurbishment plan
in development.
Facilities Manager
General Manager
DON&M
ADON/SM’s
Finance Manager
Refurbishment
Plan December
2015
programme
Poor performance related to hand
hygiene
The hospital has demonstrated high
compliance in national and local hand
hygiene audits. Inspectors observed an
improvement in performance in hand
hygiene practice during July reinspection.
1. Hand hygiene compliance
rates to be compliant with
national KPI
2. Additional training to be
targeted at Consultants and
NCHDs.
3. Encourage use of HSE land to
allow staff a choice of
training
4. Implement previously agreed
action from the Hospital
Executive Board, to publish
the names of staff who are
non compliant with Hand
Hygiene training
5. Monthly training schedule
6. Targeted training provided
July 27th (Orthopaedics)
7. Ongoing monthly sessions,
ward education.
General Manager
Clinical & Associate Clinical
Directors
Infection Control Team
DONM
ADON/SM’s
CNM’s/MM’s
Heads of Departments
July
ongoing
Monthly Audit
results
KPI’s
National KPI’s
Targeted refresher hand hygiene training
was not provided to staff in response to
the poor compliance observed in June
inspection.
9
LGH Q&R Dept. QIP/EE/October 15/version 7
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5.1
5.1.1
5.1.2
6
Alcohol gel dispensers were sticky and
unclean (Med2)
Alcohol hand rub should not be placed next
to the sink as it may be inappropriately
used instead of liquid soap.
Hand Hygiene Advisory Posters
Aspergillus control
A risk assessment and evidence of
communication and education were not
available to view by the Authority at the
time of the inspection, which outlined
measures to reduce the incidence of
invasive aspergillosis during the extensive
building works in progress. The Authority
was not assured that the risk of invasive
aspergillosis was being fully managed in
line with the Infection Prevention and
Control Standards.
10 LGH Q&R Dept. QIP/EE/October 15/version 7
8. HPSE audit October 2015
1. New dispensers installed and
product changed.
2. Included on ward and
corridor schedule
1.
IPCT consulted regarding the
appropriate placement of
alcohol gel dispensers in
clinical areas.
2. Not placed near sinks
1. Must be highly visible in all
clinical areas
2. Updated beside lifts and on
main corridors
3. Voice over and hand hygiene
stations to be installed at
Hospital entrances
1. Provide evidence to HIQA of
risk assessment between
Estates and Microbiology in
relation to Aspergillus
control for the recent
building works at LGH
2. The Infection Prevention and
Control Team revised the
policy based on the
“National Guidelines for the
Prevention of Nosocomial
Invasive Aspergillosis during
Construction/Renovation
Activities” to assess the need
Facilities Manager
Domestic staff
Ward Managers
CNM’S/CMM’s
IPCT
Daily
November 2015
September 2015
Monthly
check
December2015
Ongoing
July 2015
Monitored as
required
Maintenance
IPCT
Facilities Manager
General Manager
Infection Prevention & Control
Manager.
Consultant Microbiologist,
Estates Manager,
Facilities Manager,
General Manager
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for education
3. The Estates team liaises with
IPCM & Consultant
Microbiologist on each
project and agree the
parameters for dust control.
This is then included in the
description of works for the
Contractor.
4. Training records maintained
5. National Patient leaflets are
available
7
Safe injection practices
The management of multi-dose
medication vials were not in line with
best practice.
7.1
Storage of supplies for sterile injections
and infusions, including ampoules of
normal saline, butterfly needles, syringes,
were stored in storage carts located on
corridors outside patient rooms on Med2
Sterile supplies including swabs and
venous catheter dressings remained on
trolleys at the re-inspection
11 LGH Q&R Dept. QIP/EE/October 15/version 7
1. Revise medication policies to
evidence “Best practices for
injection and related
procedures toolkit”
(WHO 2010)
2. Multi-dose vials to be used for
Single use or single patient
use only
1. No sterile supplies are to be
stored on point of care
trolleys
2. Sterile supplies required for
injections or infusion
procedures must be
prepared in clean utility/
treatment room using an
aseptic technique, preceded
Nursing Practice Development
ADON/SM’s
DONM
Chief Pharmacist & staff
Drugs & Therapeutic
Committee
Clinical & Associate Clinical
Directors
Consultant group
NCHD’s
October 2015
On going
Medication
Metrics
All Ward Managers
ADON/SM’s
September 2015
Ongoing
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7.2
Anaesthetic drugs were drawn up in
syringes early in the morning in
anticipation of an elective afternoon
operating list. These were labelled with
the name of the drug only and stored on
a tray on a counter top.
1.
2.
3.
4.
8
8.1
ADDITIONAL KEY FINDINGS
Transmission Based Precautions
Precautionary signage was not applied in
line with best practice.
An incorrect airborne precautionary sign
was in place for a patient requiring
contact precautions.
8.2
Operating Theatre
Hand wash sinks
Maintenance programme needed for
painting, door protection, walls and
corners
Some flooring beginning to lift
12 LGH Q&R Dept. QIP/EE/October 15/version 7
by hand hygiene.
Adherence to Medication
policies- preparation,
storage and administration
of IV medications
Attendance at mandatory IV
Study day. IV revalidation
study day- a mandatory
programme that Nursing &
Midwifery staff are
requested to attend on a 2
yearly basis.
Monthly Nursing &
Midwifery Metrics
Installation of Omnicell
system in progression
ADON/SM Perioperative
Directorate
Consultant Anaesthetist
Theatre Superintendent
CNM’s/ Staff Nurses.
September 2015
Training
records
Metrics
Monthly KPI’s
First Quarter 2016
1. Adherence to IPC Policies
2. Review communication
process in relation to
isolation cleaning
requirements
3. Isolation room doors must be
closed as per patient risk
assessment
All staff
CNM’s/CMM’s
Staff Nurses/Midwives
Domestic Services
1. Refurbishment plan
2. Facilities department to
address these specific issues
3. All maintenance work is
being carried out
chronologically.
Facilities Manager
ADON/SM
GM
DONM
August 2015
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Daily
Basin in recovery not HBN compliant
Needs HMC
Scopes not processed in accordance with
best practice
Open Syringes and needles
Insufficient storage space- sterile/non
sterile
Scopes in utility transported on corridor
8.3
Care Bundles
8.4
Shared Learning
The Authority was not assured from the QIP
that learning from the June inspection with
regard to environmental hygiene was
shared across the hospital. During the July
inspection, similar environmental hygiene
issues were identified during spot checks on
all wards visited.
13 LGH Q&R Dept. QIP/EE/October 15/version 7
Storage issues to be addressed with
facilities department
Risk Assessment by external advisor
on Endoscopy Decontamination
1. Care Bundle Documentation
must be completed twice
daily as per policy
2. Fortnightly audit care
bundles
1. Information session
organised with all Heads of
departments, CNM/CMM’s
2. Dissemination of information
at meetings-Quality &
Patient Safety, HICCP, HSAG,
HEB, Team meetings.
ADON/SM
Facilities Manager
General Manager
Decontamination Committee
General Manager
DON&M
1st Quarter 2016
On going
CNM’s/ CMM’s
Staff Nurses/Midwives
Daily
Monthly
Metrics Audit
General Manager
DONM
Heads Of Departments
ADON/SM’S
Quality & Patient Safety
Committee
July 28th 2015
TBA
December
2015
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