Unannounced Theatre Inspection Report Perth Royal Infirmary NHS Tayside 12 13 July 2017 www.healthcareimprovementscotland.org
The Healthcare Environment Inspectorate was established in April 2009 and is part of Healthcare Improvement Scotland. We inspect acute and community hospitals across NHSScotland. You can contact us to find out more about our inspections or to raise any concerns you have about cleanliness, hygiene or infection prevention and control in an acute or community hospital or NHS board by letter, telephone or email. Our contact details are: Healthcare Environment Inspectorate Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone: 0131 623 4300 Email: comments.his@nhs.net Healthcare Improvement Scotland 2017 First published September 2017 This document is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-nd/4.0/ www.healthcareimprovementscotland.org
Contents 1 About this report 4 2 Summary of inspection 5 3 Key findings 7 Appendix 1 Requirements and recommendations 12 Appendix 2 Inspection process flow chart 14 3
1 About this report This report sets out the findings from our unannounced inspection of the theatre department of Perth Royal Infirmary, NHS Tayside, from Wednesday 12 July to Thursday 13 July 2017. This report summarises our inspection findings on page 5 and detailed findings from our inspection can be found on page 7. A full list of the requirements and recommendations can be found in Appendix 1 on page 12. The inspection team was made up of two inspectors. The flow chart in Appendix 2 summarises our inspection process. More information about the Healthcare Environment Inspectorate (HEI), our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/hei.aspx 4
2 Summary of inspection About the hospital we inspected Perth Royal Infirmary is a district hospital catering for both the city of Perth and the wider Perth and Kinross area. It contains 261 staffed beds and has a full range of healthcare specialties. The hospital contains 6 theatres and 2 day case theatres covering orthopaedics, general, urology and gynaecology surgery, as well as other specialist surgery. About our inspection We carried out an unannounced inspection of the theatre department of Perth Royal Infirmary from Wednesday 12 July to Thursday 13 July 2017. Inspection focus This was the first inspection of the hospital s theatre department against the Healthcare Improvement Scotland healthcare associated infection standards (February 2015). Before carrying out this inspection, we reviewed NHS Tayside s self-assessment. This informed our decision on which standards to focus on during this inspection. Standard 1: Leadership in the prevention and control of infection Standard 2: Education to support the prevention and control of infection Standard 4: HAI surveillance Standard 6: Infection prevention and control policies, procedures and guidance Standard 8: Decontamination, and Standard 9: Acquisition of equipment. We inspected the following areas: main theatre suite day surgical unit, and gynaecology theatres. What NHS Tayside did well There was positive leadership of infection prevention and control in the theatre departments. There was good compliance with the management of linen, waste and sharps. What NHS Tayside could do better All staff must take the opportunity to decontaminate their hands at appropriate moments. Theatres must be cleaned following correct cleaning methods. What action we expect NHS Tayside to take after our inspection The inspection resulted in two requirements and two recommendations. The requirements are linked to compliance with the Healthcare Improvement Scotland HAI standards. A full list of the requirements and recommendations can be found in Appendix 1. 5
An improvement action plan has been developed by the NHS board and is available on the Healthcare Improvement Scotland website www.healthcareimprovementscotland.org/hei.aspx We expect NHS Tayside to carry out the actions described in its improvement action plan to address the issues we raised during this inspection. These actions should be completed within the timeframes given in Appendix 1. We would like to thank NHS Tayside and, in particular, all staff at Perth Royal Infirmary for their assistance during the inspection. 6
3 Key findings Standard 1: Leadership in the prevention and control of infection We found evidence of positive leadership that has resulted in improvements to the prevention and control of infection in the theatres at Perth Royal Infirmary. Similar improvements have taken place across other NHS Tayside theatre departments, including Ninewells Hospital, Dundee. This demonstrates the value of the sharing and learning culture across theatre departments within NHS Tayside. Theatre staff told us they had a good relationship with the infection, prevention and control team, with the team being easy to contact by telephone or email. Staff were able to describe how and when they would contact the team for advice. We were told that a safety brief takes place in the theatre departments at the start of every shift to share information with theatre staff about patient safety issues, changes to policy, significant events and any new infection control-related issues. If necessary, any infection prevention and control issues can be raised at the weekly staff meeting. Standard 2: Education to support the prevention and control of infection We spoke with the lead nurse for infection prevention and control and the theatre operational manager about education for staff in the theatre department. NHS Tayside s education strategy highlights the need for all staff who have direct contact with patients or the care of the environment to identify HAI-specific objectives in their personal development plan. All staff confirmed that this is discussed during their annual personal development plan review meeting with their manager. Most of the staff we spoke with demonstrated a clear understanding of their role and were aware of their HAI infection-related objectives and responsibilities for the prevention and control of infection. NHS Tayside uses LearnPro, which is an educational software system for computer-based training. We were told that HAI education modules are available to all staff on LearnPro. Staff told us that they receive reminders from LearnPro to let them know what training was outstanding. The infection prevention and control team also provides a range of HAI training and education in a variety of formats, including face-to-face education sessions. Theatre staff have a monthly clinical effectiveness half day where current issues are discussed and an education session is given. This education session may be an infection control related topic. Staff told us the last education session focused on a recently introduced hand hygiene audit tool. Staff can also request training topics for future clinical effectiveness sessions which they feel would benefit them. We saw evidence that NHS Tayside is planning a promotion of the recently launched Scottish Infection Prevention and Control Education Pathway foundation layer. All staff are encouraged to undertake this training which is available on LearnPro. This will enable staff to continuously improve their knowledge and skills around infection prevention and control. Areas for improvement We saw there was no system in the theatre departments for tracking staff uptake of HAI training. We were told that the theatre manager is currently working on a system to record staff attendance at all training sessions and the completion of LearnPro modules. This would 7
include training undertaken for infection, prevention and control. We look forward to seeing progress with this at future inspections. Standard 4: HAI surveillance NHS boards are required to regularly submit data to Health Protection Scotland, including surgical site infection data. We reviewed the submitted surgical site infection data before our inspection. The data available before our inspection was up to March 2016. From this we noted that the surgical site infection rate was below the Scottish average for neck and femur operations and was average for both knee and hip arthoplasty for the period of time the data covered. During the inspection, we were told that there was a higher than normal rate of surgical site infections during April 2017. We were also told that a review meeting had been held for those directly involved, including clinicians, theatre staff, management and the infection prevention and control team. The estates team was also at the meeting to review the impact of any estates work in the theatre department. The review meeting established that the increased rate of infection was not as a result of the practices within the theatre department. Staff told us how efficiently the review process worked. Standard 6: Infection prevention and control policies, procedures and guidance NHS Tayside has adopted the current version of Health Protection Scotland s National Infection and Prevention Control Manual. This manual describes the standard infection control precautions and transmission-based precautions. These are the minimum precautions that healthcare staff should take when caring for patients to help prevent crosstransmission of infections. There are 10 standard infection control precautions, including hand hygiene and the use of personal protective equipment. The manual is available on NHS Tayside s intranet site. All staff we spoke with could tell us how to access the manual and that they are made aware of changes to the manual through ward safety briefs, handover meetings, verbally or by email. During the inspection we saw good compliance with the management of sharps, waste and linen. All staff we spoke with had a good level of knowledge and understanding of standard infection control precautions. Staff explained how they would safely manage a blood or body fluid spillage, including: the equipment they would use the precautions they would take, and the correct dilution strength of chlorine-releasing disinfectant and detergent solution. On the first day of our inspection, we saw a weaker solution of chlorine-releasing disinfectant and detergent than that required for the management of blood and body fluid spillages and we were told this was made up every day. Staff spoken with were unsure of the purpose of this solution. On the second day of our inspection, we were told that the daily practice of making up a bottle of this solution would be discontinued. 8
NHS Tayside is required to measure staff compliance with standard infection control precautions. The frequency of this compliance monitoring is determined by individual NHS boards. We saw evidence of the NHS Tayside audit tool called TEACH Tool for Environmental Auditing of the Clinical area Healthcare Associated Infection. This tool is used for environmental auditing of the clinical areas and incorporates standard infection control precaution elements. On completion, the tool is given to the senior charge nurse who takes corrective action if required. All staff spoken with told us that they received feedback from the audits during the weekly staff meeting. Staff told us that minutes from these meetings are printed and put in a communication folder that staff can access if they are unable to attend the meeting. We also saw audit results displayed on theatre department notice boards. During our inspection, we saw good dress code compliance by staff. We also saw a good supply of personal protective equipment available for staff use in the theatre department, including footwear, gloves, aprons and face masks. Areas for improvement Hand hygiene audits are not yet being carried out in the operating theatres. This was highlighted during the theatre inspection at Ninewells Hospital. We saw evidence that significant work has been carried out to implement hand hygiene audits, with a trial taking place in theatres at Stracathro Hospital, Brechin. Following the trial, hand hygiene audits are currently being rolled out at Ninewells Hospital and are due to start at Perth Royal Infirmary in July 2017. Senior management told us that ward staff carried out monthly hand hygiene audits in theatre recovery areas. We saw that hand hygiene compliance data for June 2017 was 100% for the gynaecology theatre, main theatre and day surgery unit recovery areas. However, we saw varied compliance with hand hygiene throughout the theatre department. Some staff did not decontaminate their hands after removing gloves and before starting a different task. Some staff also kept the same gloves on for different tasks. Requirement 1: NHS Tayside must ensure that, in accordance with Health Protection Scotland s National Infection Prevention and Control Manual, personal protective equipment should be removed and disposed of immediately after use and hands should be decontaminated after the completion of each task. In the gynaecology theatre and the day surgery unit, we found sterile instrument trays were stored stacked on top of each other. In the general theatre store room, trays were placed on cardboard on shelving to prevent damage to the wrapping of the trays. Storing instrument trays in this way means that the tray covers are at risk of being torn, which could cause possible contamination or damage to the sterile instruments. Health Facilities Scotland s guidance recommends the review of options to minimise or cease the stacking of wrapped sterile packs and trays. We saw new shelf racking in the orthopaedics sterile tray store which follows best practice as detailed in Health Facilities Scotland s guidance. In the day surgery unit, new shelving had been received but we were told that this was insufficient for the unit s needs. 9
Recommendation a: NHS Tayside should review the storage of sterile instrument trays, instruments and packs in line with Health Facilities Scotland s guidance on the management of reusable surgical instruments during transportation, storage and after clinical use. Standard 8: Decontamination We found that the standard of environmental cleanliness was very good across all theatre areas inspected. This included disposal holds, anaesthetic rooms, corridors, storage areas, staff changing facilities and theatre recovery areas. We looked at a variety of patient equipment throughout the hospital, including patient warming equipment, procedure trolleys, intravenous pumps and patient monitoring equipment. All equipment was clean, ready for use and in a good state of repair. We saw lead aprons stored as clean and ready for use outside a number of theatres. These are used during surgery when X-ray type equipment is being used. We looked at 88 patient positioning pieces, pressure relieving devices and theatre table mattresses and all but six of these were clean, damage free and ready for use. All staff we spoke with told us about the action they would take if they identified a damaged piece of equipment and confirmed that the equipment would be removed from use and disposed of. We discussed the procedure for the decontamination of theatre staff footwear. We were told that theatre staff are responsible for cleaning their own footwear. We saw theatre footwear stored in the changing rooms that was clean and ready for use. We found that the fabric of the theatre departments was in a good state of repair. Staff described a planned preventative programme of maintenance for the theatre department. This means that areas requiring repair or replacement are identified and documented in risk assessments along with actions to reduce any risks. We saw the certificates of calibration for the theatre ventilation system, as required by national guidance for specialised ventilation for healthcare premises. We were shown how theatre management staff can access the estates property computer drive where information about the theatre ventilation can be found as well as the information for planned preventative maintenance of the theatres. At the time of our inspection, one theatre in the main theatre suite was closed for rewiring. The HAI System for Controlling the Risk in the Built Environment (HAI SCRIBE) information had been completed and was displayed at the entrance to the theatre. This system aims to assess and manage the risks to the healthcare environment whilst works are carried out. Theatre staff told us that the works have had no negative effect on the running of the rest of the theatre suite. The operational theatre manager informed us how information about the works, including the HAI SCRIBE document, was shared between the project lead, the infection prevention and control team and the theatre managers. We were told that this information helps maintain good communication between estates, infection prevention and control team and theatre management. Areas for improvement In some theatres, we saw that positioning pieces were stored in the disposal holds which is not an appropriate storage area for clean equipment. A disposal hold is classed as a dirty 10
area and, therefore, there is potentially the risk of cross contamination of the clean equipment. Requirement 2: NHS Tayside must ensure that all positioning pieces are stored in a clean area away from potentially contaminated areas to reduce the risk of cross contamination and infection of patients. We saw some clinical hand wash basins in the main theatre suite were not compliant with current guidance. NHS Tayside told us that these have been added to their estates monitoring system and a replacement programme is under way. During the inspection, we observed staff cleaning theatres between patient cases. The recommended process to follow is for equipment to be cleaned working from top to bottom and finishing with the wheels or base to prevent recontamination of clean equipment. Cleaning starts with the highest equipment in the centre of the theatre and then outwards. We observed staff clean lower equipment such as patient trolleys and then clean higher pendant lamps. Disposable cloths should be discarded frequently to reduce the risk of cross-contamination. We saw in some cases a bucket with general detergent was used and the same cloth was used for cleaning multiple pieces of equipment. Recommendation b: NHS Tayside should review theatre cleaning practices to ensure that theatres are cleaned in a systematic way to reduce the risk of cross contamination and infection of patients. Standard 9: Acquisition of equipment We asked staff about the process they followed when ordering replacement or new equipment. They told us that NHS Tayside had an approved list of suppliers for equipment and that senior charge nurses would normally order from this list. A requisition form would be completed for anything not included on the equipment list and the infection prevention and control team would be involved. The form is used to confirm that, before any new equipment is purchased, it can be decontaminated effectively after use. 11
Appendix 1 Requirements and recommendations The actions the HEI expects the NHS board to take are called requirements and recommendations. Requirement: A requirement sets out what action is required from an NHS board to comply with the standards published by Healthcare Improvement Scotland, or its predecessors. These are the standards which every patient has the right to expect. A requirement means the hospital or service has not met the standards and the HEI is concerned about the impact this has on patients using the hospital or service. The HEI expects that all requirements are addressed and the necessary improvements are made within the stated timescales. Recommendation: A recommendation relates to national guidance and best practice which the HEI considers a hospital or service should follow to improve standards of care. Prioritisation of requirements All requirements are priority rated (see table below). Compliance is expected within the highlighted timescale, unless an extension has been agreed in writing with the lead inspector. Priority Indicative timescale 1 Within 1 week of report publication date 2 Within 1 month of report publication date 3 Within 3 months of report publication date 4 Within 6 months of report publication date Standard 6: Infection prevention and control policies, procedures and guidance Requirement 1 NHS Tayside must ensure that, in accordance with Health Protection Scotland s National Infection Prevention and Control Manual, personal protective equipment should be removed and disposed of immediately after use and hands should be decontaminated after the completion of each task (see page 9). HAI standard criterion Priority 6.1 1 Recommendation a NHS Tayside should review the storage of sterile instrument trays, instruments and packs in line with Health Facilities Scotland s guidance on the management of reusable surgical instruments during transportation, storage and after clinical use (see page 10). 12
Standard 8: Decontamination Requirement 2 NHS Tayside must ensure that all positioning pieces are stored in a clean way away from potentially contaminated areas to reduce the risk of cross contamination and infection of patients (see page 11). HAI standard criterion Priority 8.1 1 Recommendation b NHS Tayside should review theatre cleaning practices to ensure that theatres are cleaned in a systematic way to reduce the risk of cross contamination and infection of patients (see page 11). 13
Appendix 2 Inspection process flow chart We follow a number of stages in our inspection process. More information about the Healthcare Environment Inspectorate, our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/hei.aspx 14
Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on the equality protected characteristics in line with the Equality Act 2010. Please contact the Healthcare Improvement Scotland Equality and Diversity Advisor on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net to request a copy of: the equality impact assessment report, or this inspection report in other languages or formats. www.healthcareimprovementscotland.org Edinburgh Office Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone 0131 623 4300 Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP Telephone 0141 225 6999 The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland.