Altnaglevin Hospital, Londonderry - 22 November 2011

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11.0 Hygiene Practices STANDARD 7.0 HYGIENE PRACTICES Hand hygiene procedures; handling and disposal of sharps; use of PPE; use of isolation facilities and implementation of infection control procedures; cleaning of ward/department; staff uniform and work wear. Hygiene Practices Ward 3 Ward 8 Ward 31 Ward 40 Effective hand hygiene 93 68 95 85 procedures Safe handling and disposal of sharps 91 85 91 100 Effective use of PPE 100 81 81 93 Correct use of isolation 95 N/A 93 80 Effective cleaning of ward 76 79 76 76 Staff uniform and work wear 93 100 90 93 Average Score 91 83 87 88 In most cases good hand hygiene practices were observed, however in each ward instances of staff failing to follow the correct hand hygiene procedure were observed. In Ward 3 one registered nurse was observed not completing the seven step hand hygiene procedure. This was also the case in Ward 40, as two staff had long sleeves and a care assistant did not wash their hands prior to serving food. In Ward 31 a member of medical staff did not wash their hands before gathering equipment to carry out a clinical procedure or before commencing the procedure. Ward 8 was minimally compliant in the hand hygiene section. Nursing and medical staff did not carry out the seven step technique used for hand hygiene and alcohol gel; some staff when questioned quoted five steps. Staff were also observed not washing their hands after removing PPE or before commencing an ANTT procedure. Staff did not perform hand hygiene prior to meal service nor were patients offered the opportunity to clean their hands prior to meals. When questioned staff in Ward 3, 8 and 31 were unsure of the correct procedure to follow in the event of a needle stick injury. In Ward 8 a resheathed butterfly needle was observed in a sharps box. 28
Good practice was observed in effective use of PPE in Ward 3 resulting in a full compliance score. In Ward 40 a nursing assistant was observed serving meals but was not wearing an apron. Staff in Ward 31 did not wear an apron when engaged in activities where their uniform could become contaminated, for example cleaning a used commode or empting urinals and jugs which had been used to measure urine. A similar issue of staff not wearing an apron when empting a urinal was noted in Ward 8. In addition a doctor in Ward 8 was observed carrying out ANTT while wear a glove with a missing finger and a member of staff in green scrubs transporting a patient to theatre was wearing gloves unnecessarily. There were no patients in isolation in Ward 8 so this section was marked as not applicable. As previously mentioned in Standard 6, in Ward 3 alcohol wipes were supplied in a room where a patient with Clostridium difficile was being nursed. Staff confirmed that the alcohol wipes were used to clean equipment in the room. In Ward 31 there was no care pathway in place for a patient in isolation. All four wards were partially compliant in effective cleaning of the ward. The same issues were identified in each ward such as, staff were unsure of the correct dilution rates for cleaning, disinfecting or dealing with a blood spill. In Ward 3 a nursing auxiliary made up Actichlor Plus by adding 4 tablets to a bowl of water and nursing staff were inconsistent in their practice in cleaning in an isolation room. Nursing staff were not aware of the colour coding guidelines for cleaning equipment, nor were there posters with this information displayed. Recommendations 18. All staff have a responsibility to ensure that hand hygiene is carried out in line with WHO guidelines and that all PPE is used appropriately. 19. Systems and processes should be in place to assure that staff knowledge and practice is kept up to date regarding isolation, cleaning and decontamination of equipment. 20. Systems and processes should be in place to assure that staff knowledge and practice is kept up to date regarding the use of disinfectants. 29
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 1 Areas Inspected Ward 3 Ward
Page 7 and 8: Table 7 Hygiene Practices Ward 3 Wa
Page 9 and 10: 3.0 Inspections The DHSSPS has devi
Page 11 and 12: 5.0 Audit Tool The audit tool used
Page 13 and 14: 6.0 Environment STANDARD 2.0 GENERA
Page 15 and 16: also evidence of communal products
Page 17 and 18: Additional Issue In Ward 8 the lift
Page 19 and 20: assurance that cleaning is carried
Page 21 and 22: potential airborne contamination. T
Page 23 and 24: The lift lobby in Ward 8 was being
Page 25 and 26: 9.0 Patient Equipment STANDARD 5.0
Page 27 and 28: 10.0 Hygiene Factors STANDARD 6.0 H
Page 29: Recommendations 13. The trust shoul
Page 33 and 34: 13.0 Summary of Recommendations 1.
Page 35 and 36: Reporting & Re-Audit Episode of Ins
Page 37 and 38: 16.0 Action Plan Reference number R
Page 39 and 40: Reference number damage Recommendat
Page 41 and 42: Reference number Recommendations 18

Altnaglevin Hospital, Londonderry - 22 November 2011

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