HIQA’s monitoring programme -

National Standards for the

Prevention and Control of Healthcare

Associated Infections: Operating Associated Infections: Operating

theatre findings 2015.

Katrina Sugrue

Inspector HIQA

The Authority’s role

“is to promote safety and quality in the provision of health, and personal social provision of health, and personal social services for the benefit of the health and welfare of the public”

(Section 7 of the Health Act 2007).

What HIQA Expects

Applicable National Standards

for Acute Hospital Services

Perioperative care: a unique

environment

• Source of a significant percentage of patient safety-related adverse events.

– Many variable challenges– Many variable challenges

– Complex clinical care

– High cost

– Sophisticated technologies

– Storage of supplies (implants and instruments)

– Reprocessing of invasive devices

Clinical Adverse Events reported in

2012

Clinical Adverse Events reported in 2012

The Irish National Adverse Events Study (INAES): the

frequency and nature of adverse events in Irish

hospitals—a retrospective record review study

• Prevalence of adverse events in acute Irish

hospitals 12.2%

• 10.3 events per 100 admissions

• 70% preventable• 70% preventable

• 2/3 rate mild to moderate impact on patient

• A mean 6.1 added bed days attributed to

events

• €5550 per event

Healthcare Associated Infection and

Antimicrobial Use

• Hospital Acquired Infection (HAI)

�1 in 20 patients

�Surgical site infections - 18.2%�Surgical site infections - 18.2%

�Pneumonia - 17.2%

�Urinary tract infections - 15.0%

�Bloodstream infections - 13.2%

Source: Health Protection Surveillance Centre, Point Prevalence Survey of Hospital Acquired Infections & Antimicrobial Use in European Acute Care

Hospitals: May 2012 – Republic of Ireland National Report: November 2012.

PCHCAI Standards

Standard 3

Standard

12 National Standards

•Governance and Management

•System

Structures and Processes

•Environment and Facilities management

•HR ManagementStandard

6

Standard 8

12 National Standards

• Governance and Management

• System

Structures and Processes

• Environment and Facilities management

• HR Management

• Communication Management

• Hand Hygiene

• Communicable/Tr

•HR Management

•Communication Management

•Hand Hygiene

•Communicable/Transmissible Disease Control

•Microbiological Services

• Invasive Medical Devices

•Outbreak Management

•Surveillance Programme

•Antimicrobial Stewardship

Unannounced Inspections 2015

• Acute publically funded hospitals

• Standard 3 – Environmental hygiene

• Standard 6 – Hand hygiene

• Standard 8 – Invasive devices• Standard 8 – Invasive devices

• Other standards

• Minimum 1-3 areas inspected

• Triangulation (observation, discussion and documentation)

• Six week re-inspection

• Report

Standard 3

The physical environment, facilities and resources are developed and managed to

minimise the risk of service users, staff and visitors acquiring a Healthcare

Associated Infection

Equipment

Cleanliness of the Environment

Design and Facilities

Monitoring and Evaluation of Quality of Hygiene Services

Water Systems

Construction

Isolation facilities

Equipment

2015 inspections focused on high risk areasThe high-risk areas inspected included:

-haematology units

- oncology units

- day infusion services

- intensive care units - intensive care units

- coronary care units

- operating theatres

- endoscopy suites

- interventional radiology suites and

- renal dialysis units.

Findings

2

2

2

3

5

6

7

10

14

Radiology Department

Endoscopy Unit

Delivery Ward

Renal Dialysis Unit

Intensive Care Unit

Day Ward

Oncology Unit

Operating Theatre Department

General Ward (Medical/Surgical)

• 39 unannounced inspections in 32 hospitals

• 7 re-inspections

• 2 out of 7 re-

1

1

1

1

1

1

1

1

1

2

2

2

Neonatal Intensive Care Unit

Maternity Ward

Infusion Unit

Ear, Nose and Throat …

Cardiac Rehabilitation Unit

Postnatal Ward

Paediatrics

Orthopaedic

Coronary Care Unit

Physiotherapy Department

Rehabilitation Ward

Radiology Department • 2 out of 7 re-inspections in theatres

• 64 clinical areas inspected

• 10 theatres inspected

2

2

2

2

2

2

3

3

4

4

6

6

6

9

windows not sealed

reprocessing of reusable invasive medical …

lack of patient sanitary facilities

lack of or inadequate hygiene audits

lack of a domestic store room

blood glucose monitoring holder

inappropriate storage of supplies in …

alcohol hand rub not at the point of care

lack of storage

environmental hygiene

maintenance

infrastructure

hand wash sinks not HBN 00-10 compliant

safe injection practices

Main findings in

1

1

1

1

1

1

1

1

1

1

1

1

2

transmission based precautions

theatre department not self contained

personal belongings in operating theatre

open doors in sterile prep room

open doors in shared scrub room

no waste storage facilities

no hand wash sink in dirty utility room

no dirty utility room

insufficient allocated cleaning resources

inconsistent management of blood spillages

doors to operating room not closed/sealed

appropriate facilities for children

windows not sealed

Main findings in

theatre inspections

in 2015

Infrastructure

• Dated infrastructure

• RIMD facilities

• Restricted access

• Small sized operating

• Lack of storage

• fire exits

• Laminar flow

systems that require • Small sized operating

theatres

• Separation of clean and

dirty processes

systems that require

replacement

• Lack of patient toilet

facilities

• No bedpan washer

Maintenance

• ‘Health Boards should ensure that the healthcare

environment does not compromise effective infection

prevention and control, and that poor maintenance

practices, such as the acceptance of non-intact surfaces

that could compromise effective infection prevention and

control practice, are not tolerated.’

Source. APS Group Scotland. The Vale of Leven Hospital Inquiry Report. [Online]. Available from:

http://www.valeoflevenhospitalinquiry.org/Report/j156505.pdf

Storage

• Limited storage

• Clutter

• Inappropriate storage of sterile supplies

Cleaning

•Standard of cleaning

•Scheduling/supervision

•Storage for cleaning equipment

•Management of cleaning equipment

Standard 6

Hand hygiene practices that prevent, control and reduce the risk of the

spread of Healthcare Associated Infections are in place

Hand hygiene policies procedures and systems are in

placeplace

Service users and relatives are informed

Monitoring and audit of hygiene

practices

Standard 8

invasive medical device related infections are prevented or

reduced

Invasive medical devices are

managed in line with best practicewith best practice

Relevant staff are

competently trained

Monitoring, and audit with

quality improvement

actions to improve

service user care

APIC Guidelines on Safe Injection Practice

“Outbreaks involving the transmission of bloodborne

pathogens or other microbial pathogens to patients in

various types of healthcare settings due to unsafe

injection, infusion, and medication vial practices are

unacceptable”

• Since 2001, at least 50

outbreaks involving

unsafe injection practices

were reported to CDC

• 90% occurred in

outpatient settings44%56% outpatient settings

• Many hundreds of

infected patients

• Over 150,000 patient

notified and tested

44%56%

BACTERIAL

INFECTION

VIRAL

HEPATITIS

Transmission of infection related to

unsafe practices

� syringe reuse between patients during parenteral medication

administration to multiple patients

� contamination of medication vials or intravenous (IV) bags after having

been accessed with a used syringe and/or needle,

� failure to follow basic injection safety practices when preparing and � failure to follow basic injection safety practices when preparing and

administering parenteral medications to multiple patients

� inappropriate use and maintenance of finger stick devices and glucometer

equipment used on multiple patients.

APIC POSITION PAPER:SAFE INJECTION, INFUSION, AND MEDICATION VIAL PRACTICES IN HEALTH CARE (2016)

http://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/2016APICSIPPositionPaper.pdf

Issues relating to medication

safety

00 0 0

02/10

2/10

8/10

open multidose vial

priming of intravenous fluids

7/10

8/10

insufficient labelling of pre-prepared anaesthetic intravenous medications

pre-prepared syringes of anaesthetic intravenous medications

inappropriate storage of pre-prepared anaesthetic intravenous medications

APIC recommendations 2016

• Training and competency evaluations

• Guidelines and standards for safe infusion

and injection practices

• Engineering and work place controls• Engineering and work place controls

• Compliance with best practice in

preparation, storage and administration of

intravenous medicines

Miscellaneous findings

•Data protection

•Lack of privacy in recovery

•Personal belongings

•Transmission based precautions

•Management of blood spillages

The journey

References

•Dolan et al. Association for professionals in Infection Control and Hospital Epidemiology, APIC position paper: Safe injection, infusion, and medication vial practices in health care 2016. [Online]. Available from: http://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/2016APICSIPPositionPaper.pdf•Department of Health, United Kingdom. Health Building Note 26. Facilities for surgical procedures: Volume 1.

[Online]. Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/148490/HBN_26.pdf

•Department of Health, United Kingdom. Health Building Note 00-09 Infection control in the built environment.

2013. [Online]. Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170705/HBN_00-

09_infection_control.pdf.

•Department of Health, United Kingdom. Health Building Note 00-09 Infection control in the built environment. •Department of Health, United Kingdom. Health Building Note 00-09 Infection control in the built environment.

2013. [Online]. Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170705/HBN_00-

09_infection_control.pdf.

•The British Standards Institute. PAS 5748:2014 Specification for the planning, measurement and review of

cleanliness services in hospitals. [Online]. Available from:

http://shop.bsigroup.com/ProductDetail/?pid=000000000030292594

•National Hospital Office, Quality, Risk & Customer, Care. HSE Cleaning Manual Acute Hospitals. September

2006..[Online]. Available from:

http://www.hse.ie/eng/services/publications/hospitals/HSE_National_Cleaning_Standards_Manual.pdf

•National Hospital Office, Quality, Risk & Customer, Care. HSE Cleaning Manual Appendices. September

2006..[Online]. Available from:

http://www.hse.ie/eng/services/publications/hospitals/HSE_National_Cleaning_Standards_Manual_Appendic

es.pdf.

QUESTIONS