HIQA s monitoring programme - National Standards for the Prevention and Control of Healthcare. theatre findings Katrina Sugrue Inspector HIQA

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1 HIQA s monitoring programme - National Standards for the Prevention and Control of Healthcare Associated Infections: Operating theatre findings 205. Katrina Sugrue Inspector HIQA

2 The Authority s role is to promote safety and quality in the 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).

3 What HIQA Expects

4 Applicable National Standards for Acute Hospital Services

5 Perioperative care: a unique environment Source of a significant percentage of patient safety-related adverse events. Many variable challenges Complex clinical care High cost Sophisticated technologies Storage of supplies (implants and instruments) Reprocessing of invasive devices

6 Clinical Adverse Events reported in 202

7 Clinical Adverse Events reported in 202

8 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 2.2% 0.3 events per 00 admissions 70% preventable 2/3 rate mild to moderate impact on patient A mean 6. added bed days attributed to events 5550 per event

9 Healthcare Associated Infection and Antimicrobial Use Hospital Acquired Infection (HAI) in 20 patients Surgical site infections - 8.2% Pneumonia - 7.2% Urinary tract infections - 5.0% Bloodstream infections- 3.2% Source: Health Protection Surveillance Centre, Point Prevalence Survey of Hospital Acquired Infections & Antimicrobial Use in European Acute Care Hospitals: May 202 Republic of Ireland National Report: November 202.

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12 PCHCAI Standards Standard 3 Standard 6 Standard 8 2 Natio nal Stand ards Gov erna nce and Man age men t Syst em Stru ctur es and Proc esse s Envi ron men t and Facil ities man age men t HR Man age men t Com mun icati on Man age men t Han d Hygi ene Com mun icabl e/tr 2 National Standards Governance and Management System Structures and Processes Environment and Facilities management HR Management Communication Management Hand Hygiene Communicable/Transmissible Disease Control Microbiological Services Invasive Medical Devices Outbreak Management Surveillance Programme Antimicrobial Stewardship

13 Unannounced Inspections 205 Acute publically funded hospitals Standard 3 Environmental hygiene Standard 6 Hand hygiene Standard 8 Invasive devices Other standards Minimum -3 areas inspected Triangulation (observation, discussion and documentation) Six week re-inspection Report

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15 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 Design and Facilities Cleanliness of the Environment Equipment Isolation facilities Construction Water Systems Monitoring and Evaluation of Quality of Hygiene Services

16 205 inspections focused on high risk areas The high-risk areas inspected included: -haematology units - oncology units - day infusion services - intensive care units - coronary care units - operating theatres - endoscopy suites - interventional radiology suites and - renal dialysis units.

17 Findings General Ward (Medical/Surgical) Operating Theatre Department Oncology Unit Day Ward Intensive Care Unit Renal Dialysis Unit Delivery Ward Endoscopy Unit Radiology Department Rehabilitation Ward Physiotherapy Department Coronary Care Unit Orthopaedic Paediatrics Postnatal Ward Cardiac Rehabilitation Unit Ear, Nose and Throat Infusion Unit Maternity Ward Neonatal Intensive Care Unit unannounced inspections in 32 hospitals 7 re-inspections 2 out of 7 reinspections in theatres 64 clinical areas inspected 0 theatres inspected

18 safe injection practices hand wash sinks not HBN 00-0 compliant infrastructure maintenance environmental hygiene lack of storage alcohol hand rub not at the point of care inappropriate storage of supplies in blood glucose monitoring holder lack of a domestic store room lack of or inadequate hygiene audits lack of patient sanitary facilities reprocessing of reusable invasive medical windows not sealed appropriate facilities for children doors to operating room not closed/sealed inconsistent management of blood spillages insufficient allocated cleaning resources no dirty utility room no hand wash sink in dirty utility room no waste storage facilities open doors in shared scrub room open doors in sterile prep room personal belongings in operating theatre theatre department not self contained transmission based precautions Main findings in theatre inspections in 205

19 Infrastructure Dated infrastructure RIMD facilities Restricted access Small sized operating theatres Separation of clean and dirty processes Lack of storage fire exits Laminar flow systems that require replacement Lack of patient toilet facilities No bedpan washer

20 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:

21 Storage Limited storage Clutter Inappropriate storage of sterile supplies

22 Cleaning Standard of cleaning Scheduling/supervision Storage for cleaning equipment Management of cleaning equipment

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24 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 place Monitoring and audit of hygiene practices Service users and relatives are informed

25 Standard 8 invasive medical device related infections are prevented or reduced Invasive medical devices are managed in line with best practice Monitoring, and audit with quality improvement actions to improve service user care Relevant staff are competently trained

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27 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

28 Since 200, at least 50 outbreaks involving unsafe injection practices were reported to CDC 90% occurred in 56% 44% outpatient settings BACTERIAL INFECTION VIRAL HEPATITIS Many hundreds of infected patients Over 50,000 patient notified and tested

29 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 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 (206)

30 Issues relating to medication safety /0 0 open multidose vial 8/0 2/0 priming of intravenous fluids 8/0 7/0 insufficient labelling of preprepared anaesthetic intravenous medications pre-prepared syringes of anaesthetic intravenous medications inappropriate storage of pre-prepared anaesthetic intravenous medications

31 APIC recommendations 206 Training and competency evaluations Guidelines and standards for safe infusion and injection practices Engineering and work place controls Compliance with best practice in preparation, storage and administration of intravenous medicines

32 Miscellaneous findings Data protection Lack of privacy in recovery Personal belongings Transmission based precautions Management of blood spillages

33 The journey

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35 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 206. [Online]. Available from: pdf Department of Health, United Kingdom. Health Building Note 26. Facilities for surgical procedures: Volume. [Online]. Available from: Department of Health, United Kingdom. Health Building Note Infection control in the built environment [Online]. Available from: Department of Health, United Kingdom. Health Building Note Infection control in the built environment [Online]. Available from: The British Standards Institute. PAS 5748:204 Specification for the planning, measurement and review of cleanliness services in hospitals. [Online]. Available from: National Hospital Office, Quality, Risk & Customer, Care. HSE Cleaning Manual Acute Hospitals. September [Online]. Available from: National Hospital Office, Quality, Risk & Customer, Care. HSE Cleaning Manual Appendices. September [Online]. Available from: es.pdf.

36 QUESTIONS