Cleaner Hands Patient Safety Alert Monitoring Audit

Transcription

1 Cleaner Hands Patient Safety Alert Monitoring Audit Audit Title Cleaner Hands Patient Safety Alert Monitoring Audit Audit Date January 2009 Report completed date February 2009 Author Paula Bennett Author s Job Title Clinical Audit & Effectiveness Manager Department Clinical Audit & Effectiveness Department Audit Lead Val Newton Specialty Patient Safety Division

2 Introduction The reduction of MRSA bacteraemia can be attributed in part to the improvement of hand hygeine of healthcare staff. The National Patient Safety Agency (NPSA) alert, Clean Hands Save Lives (Sept 2008) informs that infection rates can be significantly reduced (15%) where hand hygeine improvements have been made. The Trust is required to undertake audit in order to monitor compliance with the alert and to review current risk management strategies by examining current hand hygeine facilities. The audit looks at the placement, accessibility and suitability of hand hygeine products including hand wash basins and hand wash dispensers. Aim To ensure that the Trust is compliant Standards National Patient Safety Agency Clean Hands Save Lives (Sept 2008) Methodology A data collection form was distributed across the Trust in order to obtain an inventory of hand hygeine facilities. Once completed, the forms were returned to the PA to the Chief Nurse who collated and added the information to an excel spreadsheet. The Clinical audit department then analysed the information and produced this report. 2

3 Results Eighty five completed data collection forms were returned to the Clinical audit Department for collation and analysis. Of the 84 data collection forms received, 50 areas / specialties were covered with 415 separate entries, the areas responding are detailed below:- A&E Endoscopy NICU Appleton unit Main catering stores Stanhoe Audiology Main kitchen catering dept Terrington Brancaster clinic Marham West Dereham - orthopaedic pre-assessment Cardio / resp dept MAU West Dereham Rheumatology Castleacre Ward Microbiology West Raynham Cellular pathology Necton West Raynham Rehab gym Clinical Health Psychology Necton rehab gym Wheelchair service Clinical Neurophysiology Newton Rehab gym Radiology Critical Care Unit Occupational Therapy Roxburgh children s centre Denver Orthopaedic outpatient Shouldham Dermatology Macmillan areas outpatients Staff dining room/coffee shop Diabetes Outpatients Gum Domestic Services Oxborough Haemo-chemistry & phlebotomy Elm Pathology - blood training room Leverington Ward Feltwell Pentney Macmillan outpatient areas Gayton Physiotherapy Clinical to non clinical area ratio:- Non clinical 38% Clinical 62% Five hand hygeine facilities were observed and documented, the facilities were:- 1. Glove holders 2. Hand basins 3. Hand rub dispensers 4. Moisturiser dispensers 5. Soap dispensers 3

4 1. Glove holders Of the 84 completed data collection forms, twenty two (26%) areas / specialties reported that they had glove holders with a total of 141 holders between them, seven on average per area. Where glove holders were available all were visible, easily accessible and placed at normal height. Just three were easily activated and clearly labelled. Five data collection forms reported that the area didn t have glove holders but used gloves directly from the boxes. The following areas reported that they had no glove holders. Appleton unit Audiology Brancaster clinic Castleacre Ward Cellular pathology Clinical Health Psychology Clinical Neurophysiology Dermatology Diabetes Domestic Services Endoscopy Gum Necton rehab gym Newton Rehab gym Occupational Therapy Orthopaedic outpatient Outpatient Macmillan areas Physiotherapy Roxburgh children s centre Staff dining room/coffee shop West Dereham - orthopaedic pre-assessment West Dereham Rheumatology West Raynham West Raynham Rehab gym Wheelchair service 2. Hand basins Fifty two (62%) of the areas responding said that they had hand basins, from one hand basin in one area to up to 42 hand basins on a ward. The median was documented at eight and the mean 10 hand basins. The following areas reported that they had no hand basin provision, Domestic services, Necton rehab gym, Newton rehab gym, West Raynham rehab gym and the Wheelchair service. 4

5 3. Hand rub dispensers Sixty percent (50) of the forms returned stated that there was a hand rub dispenser in the area of work. One area had a total of 54 hand rub dispensers, some wall mounted and some pump dispensers. On average each of the 50 areas reporting had around 16 hand rub dispensers. Thirty four areas had no hand rub dispensers, these areas were, domestic services, Main catering stores, wheelchair service, diabetes and microbiology. 4. Moisturiser dispensers Completed data collection forms were received from 55% (46) of areas reporting the provision of moisturiser dispensers (2 had hand barrier cream). 5. Soap dispensers Eighty forms returned said that they had soap dispensers. For these areas the soap dispensers were visible, easily accessible, placed at normal height, easily activated and clearly labelled. Where soap dispensers were not available these areas were highlighted:- Newton rehab gym, Necton rehab gym and Audiology. The following matrix shows the visibility and accessibility for each of the five facilities looked at compared to each of the areas or specialties returning completed data collection forms. Twenty two areas responding said that they had glove holders; fifty two had at least one hand basin, 50 said that they had hand rub available, 46 areas / specialties had moisturiser dispensers and 80 of the 84 areas responding reported that they had at least one soap dispenser in their area / specialty. Total number of areas / specialties responding Are they visible? Are they easily accessible? Are they placed at normal height? Are they easily activated? Are they clearly labelled? Glove holders 22 22(100%) 22(100%) 22(100%) 3(14%) 3(14%) Hand basins 52 50(96%) 50(96%) 50(96%) 6(12%) 6(12%) Hand rub 50 49(98%) 49(98%) 48(96%) 49(98%) 47(94%) Moisturiser dispenser 46 44(96%) 44(96%) 44(96%) 44(96%) 43(93%) Soap dispenser 80 80(100%) 80(100%) 80(100%) 80(100%) 79(99%) 5

6 Facilities by Directorate. Each specialty or area within the Trust is headed by one of four directorates. These directorates are Clinical Support services, Elective care, Emergency care and Women & Children s directorate. In the following chart, each of the specialties returning completed data collection forms have been shared across the four directorates. For example, there were five areas responding from the Women & Children s directorate, these were: Appleton unit Brancaster Clinic Castleacre ward NICU Roxburgh Children s Centre The following matrix shows the number of responses for each of the facilities looked at, Total number (areas) Glove holders Hand basins Hand rub Moisturiser dispenser Soap dispenser Clinical Support Services Elective Care Emergency Care Women & Children Conclusions Whilst the majority of areas within the Trust have appropriate hand hygiene facilities ( e.g accessibility to gloves, hand basins, hand rub, soap and moisturisers). It is apparent that some areas do not have sufficient placement of these facilities within certain settings i.e Many areas do not have glove holders Appleton unit Audiology Brancaster clinic Castleacre Ward Cellular pathology Clinical Health Psychology Clinical Neurophysiology Dermatology 6

7 Diabetes Domestic Services Endoscopy Gum Necton rehab gym Newton Rehab gym Occupational Therapy Orthopaedic outpatient Outpatient Macmillan areas Physiotherapy Roxburgh children s centre Staff dining room/coffee shop West Dereham - orthopaedic pre-assessment West Dereham Rheumatology West Raynham West Raynham Rehab gym Wheelchair service There are insufficient hand basins within some areas e.g in some ward areas there are no hand basins outside bay 5 due to the layout of the ward ( staff are able to access hand basin outside the adjacent bay). The following areas reported that they had no hand basin provision, Domestic services, Necton rehab gym, Newton rehab gym, West Raynham rehab gym and the Wheelchair service. There are areas where there are insufficient hand rub Thirty four areas had no hand rub dispensers, these areas were, domestic services, Main catering stores, wheelchair service, diabetes and microbiology. Only half of the Trust has access to moisturiser. Recommendations Each division to be given individual data for their specific areas to address areas for further action: All areas to ensure they have glove holders located for easy staff access 7

8 Each division to consider the number of hand basins within each area / department and ensure that there are sufficient numbers in each area to meet hand hygiene requirements for each specific area. Each division to consider signage for hand hygiene facilities within each area and department and to ensure these areas can be easily located. All areas to ensure they follow the system of cleaning hand rub / soap dispensers as stated in the Trust s cleaning folder A copy of this audit will be placed on the Trust s website as required by the NPSA alert : clean hands save lives and a written report of the 7 steps undertaken to implement the alert will be sent to the Chief Executive as required by the by the aforementioned alert. Val Newton Lead Nurse Practice and Innovation March 13 th

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