Healthcare Associated Infection (HAI) inspection tool Hospital: Ward/Department: Inspector: Date: Guidance note: This tool is designed to assist HEI inspectors assess NHS boards compliance with NHS Quality Improvement Scotland (NHS QIS) Healthcare Associated Infection standards (2008). It also reflects the critical elements of standard infection control precautions and other key national policies and standards which all NHS hospitals must comply with. During inspection, compliance with these key elements will be recorded and, in addition, inspectors will record other observations of practice, policy or other issues which provide evidence of both good and non-compliant practice. Inspectors may use digital cameras to capture images of particular concern or to highlight examples of good practice. These images will not include images of patients, their relatives or staff. Where appropriate, these images will be included in the published inspection report. If the inspector identifies any serious concern during the inspection, this will be brought to the attention of the lead inspector in the first instance. Any area of serious concern which requires immediate action will be brought to the attention of the person in charge and senior management of the hospital before the inspection team leaves the premises. These concerns will also be reported to the Chief Inspector, HEI. File Name:20120209 HAI inspection aide Version:1.3 Date: 2 April 2012 Produced by: L. Guthrie Page: Review Date:
1. Environment& Estates [Standard 4] the healthcare environment is clean and well maintained. There is a NHS board wide system in place to detail and record how often, and by whom, cleaning duties required by the NHS Scotland National Cleaning Services Specification, the NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection and the current version of Scottish Health Facilities Note 30 are performed. Critical points criteria The environment is clean, dust & grit free Clinical/ treatment room Patient bed space/ward area Linen store Kitchen Bathrooms/ toilet areas Sluice YES NO YES NO YES NO YES NO YES NO YES NO YES NO DSR The environment is intact and in good repair Fixtures & fittings are intact and in good repair The environment is free from clutter There is no inappropriate storage There is no evidence of infestation There are dedicated hand hygiene facilities There is appropriate provision of waste disposal Fridge/freezer temperature records are available There are no communal/shared toiletries in use Colour coded cleaning equipment is available (conventional cleaning equipment only) All sterile stock is in date Produced by: L. Guthrie Page: 2 of 13 Review Date: INITIALS:
Physical Environment - Free Text/Observations/Comments Produced by: L. Guthrie Page: 3 of 13 Review Date: INITIALS:
2. Communication, information & education [Standards 1, 2 & 5] Patients, their family/carers and the public are provided with up-to-date HAI information relevant to their needs. Staff have received infection control education and training relevant to their role, and have the opportunity to access additional ongoing education and training in line with national and local priority areas. Up-to-date policy information is available at ward/department level. Patient & public Information Audit Criteria Y N NA Free Text/observations/comments A range of HAI patient information leaflets are available in the department Information leaflets are up to date with a review date visible Up to date surveillance data is displayed (appropriate to department) Up to date audit data (hands, environment & mattress) is available (appropriate to department) Infection prevention & control education is provided at induction for all staff Staff have attended infection prevention & control education or training in the past year Staff have received hand hygiene training Staff training records are available at ward level Staff Education Staff can access e-learning infection control training programmes (eg NES or local programmes) Antimicrobial prescribing & stewardship training has been provided for nursing and medical staff Senior charge nurse has completed the Cleanliness Champions programme Domestic staff have received infection control education & training Produced by: L. Guthrie Page: 4 of 13 Review Date: INITIALS:
Audit Criteria Y N NA Free Text/observations/comments Domestic staff have received training on the National Cleaning Specifications & colour coding system (including micro fibre systems if in use) Staff can access infection control policies Policies Domestic Cleaning Infection control policies are up to date (hard copy & electronic) Staff can access up to date antimicrobial prescribing policy and information Cleaning schedules are available in the department The frequency of cleaning reflects the national cleaning specification There is a system of sign off in place for cleaning schedules at ward level There is a system in place to provide local and board wide assurance that micro fibre systems are being implemented and followed correctly OBSERVATION: Domestic staff use/change PPE appropriately An estates log/maintenance book is available Estates There is a system in place to inform the charge nurse of planned works Appropriate environmental controls are implemented during work There is a system to record and action estates issues identified from environmental or cleaning services audits. Nurse in charge is involved in estates monitoring activity within the ward Infrequently used outlets have a planned provision for running water weekly Produced by: L. Guthrie Page: 5 of 13 Review Date: INITIALS:
3. Standard infection control precautions [Standard 3] Healthcare staff adhere to evidence based policies, procedures and guidelines which minimise the risk of infection to patients, visitors and staff. Critical points -Audit criteria Y N NA Free text/comments/observations Any patients with known infections are appropriately isolated Isolation rooms have en-suite facilities and a clinical hand wash basin If isolation not possible, there is documented risk assessment available in the patient notes/care plan Patient placement If isolated, compliance with isolation precautions is demonstrated (e.g. door closed) If isolation precautions cannot be applied, there is evidence of documentation of this in the patient records. Used linen is not rinsed/shaken or sorted on removal from beds A laundry receptacle is available at the point of use Linen Linen bags are not overfilled Produced by: L. Guthrie Page: 6 of 13 Review Date: INITIALS:
Audit Criteria Y N NA Free Text/observations/comments There is correct segregation of used/soiled and infectious linen Clean linen is stored appropriately (e.g. not in a bathroom, no inappropriate items) There is an adequate stock of linen available Healthcare waste is segregated in line with waste regulations (including sharps bins) Healthcare waste is disposed of immediately as close to the point of use as possible All liquid waste is rendered safe using a gel agent or similar before disposal Waste bags are no more than ¾ full Healthcare waste is stored securely prior to uplift All waste bins are foot operated, lidded and clean. Waste All healthcare waste is labelled before disposal Produced by: L. Guthrie Page: 7 of 13 Review Date: INITIALS:
Audit Criteria Y N NA Free Text/observations/comments Sharps bins comply with UN3291/BS7320 Sharps bins are free from protruding sharps/are not overfilled Sharps bins are correctly assembled & labelled Temporary closure mechanisms are in use Sharps are disposed of at the point of use Sharps Sharps waste is secured securely prior to uplift Alcohol hand gel is available at ward entrances Hand hygiene There is clear signage throughout the department guiding staff, patients and visitors on appropriate use of hand hygiene products All staff in the clinical area are compliant with national dress code & uniform policy Produced by: L. Guthrie Page: 8 of 13 Review Date: INITIALS:
Audit Criteria Y N NA Free Text/observations/comments Staff are seen to take the opportunity for hand hygiene in accordance with WHO 5 Key Moments Staff use the correct technique when carrying out hand hygiene Dedicated hand wash sinks area available in all clinical areas There is one sink per 4 beds in in-patient areas All hand wash sinks are accessible Hand hygiene Hand wash basins are appropriate for use (no plugs, overflows etc) & compliant with SHFN 30 9.216 All hand wash sinks are clean A supply of appropriate PPE (eg sterile/non sterile gloves, plastic aprons) is available close to the point of use PPE is stored appropriately (avoids contamination) PPE Produced by: L. Guthrie Page: 9 of 13 Review Date: INITIALS:
Eye protection is available Audit Criteria Y N NA Free Text/observations/comments Facemasks are available Staff change PPE (gloves and aprons) after each task and/or completion of clinical procedure or task Reusable PPE (footwear, eye protection) is stored clean Produced by: L. Guthrie Page: 10 of 13 Review Date: INITIALS:
Occupational exposure Audit Criteria Y N NA Free Text/observations/comments Staff can explain the correct first aid required following an occupational exposure incident Staff are aware of how, where and when to report an occupational exposure incident Reusable patient equipment is visibly clean : Managing Patient Equipment Commodes Raised toilet seats Drip stands/iv pumps Patient monitoring equipment (including near patient testing) Manual handling equipment Lockers/tables Produced by: L. Guthrie Page: 11 of 13 Review Date: INITIALS:
Audit Criteria Y N NA Free Text/observations/comments Chairs/footstools Reusable equipment is cleaned between each patient use Reusable equipment is cleaned at predefined intervals as part of an equipment cleaning schedule (view schedule) There is an effective system in place which indicates to users that the equipment is clean and ready for use Appropriate cleaning materials area available Equipment is cleaned following exposure or contamination with blood/body fluid Equipment is decontaminated before inspection, servicing or repair Equipment for repair is accompanied by a decontamination certificate Managing Patient Equipment Mattresses are clean (inside & out) There is a regular programme of mattress checks and audit Bed rails and frames are clean Patient washbowls are disposable or clean, dry and stored inverted Produced by: L. Guthrie Page: 12 of 13 Review Date: INITIALS:
4. Clinical Practices [standard 3] there are robust systems and processes in place that ensure a consistent approach to clinical interventions, reducing the risk of infection to patients, visitors and staff. Critical points -Audit criteria Y N NA Free text/comments/observations There is a policy/care bundle/protocol in place for the Please record which type of device is being inspected. insertion and maintenance of the invasive device (e.g. Cannula, urinary catheter, central line) There is evidence in patient notes/care plan that the invasive device is reviewed each day Staff use SICPs when accessing the device Invasive devices (e.g. urinary catheters, cannula) Appropriate skin/patient preparation is used prior to device insertion (eg 2% CHG for CVC) Sterile transparent dressings are used to cover vascular access devices. Dressings are visibly clean & intact at the time of inspection Devices are removed at the earliest opportunity. Ask staff to explain how this works. View documentation. Infusions (IV) or drainage devices (catheter bags) are maintained as closed systems. Urinary catheter bags are secured above floor level & below patient waist level Produced by: L. Guthrie Page: 13 of 13 Review Date: INITIALS: