National Maternity Hospital. Founded in 1894

Transcription

1 National Maternity Hospital. Founded in 1894 Quality Improvement Plan HIQA unannounced on-site assessment October 7 th 2013 On October 7 th 2013, The Health Information & Quality Authority (HIQA) held an unannounced on-site assessment of compliance with Standard 3 (Environment & Facilities Management) and Standard 6 (Hand Hygiene) of the National Standards for the Prevention & Control of Healthcare Associated Infections. The auditors visited Unit 3 (Antenatal Ward) and Postnatal Ward 1. Standard 3 (Environment & Facilities Management): HIQA found evidence of good practice and found that the patient environment was generally clean in both areas. However HIQA found that there were opportunities for improvement regarding the cleanliness of the patient equipment and storage of same. The National Maternity Hospital has developed a Quality Improvement Plan to address these issues. Standard 6 HIQA observed that hand hygiene compliance indicated that a culture of hand hygiene is not yet operationally embedded throughout the hospital. The National Maternity Hospital is fully committed to achieving full compliance with Standard 6 and since the unannounced visit a lot of work has been carried out to ensure compliance is reached. The National Maternity Hospital has developed a Quality Improvement Plan to address this. The Authority acknowledged the infrastructural challenges of an older building and has noted that the hospital has an plan to reconfigure storage to reduce storage in corridors. We welcome the commitment of the present government to redeploy to a purpose built facility on a general campus. In the interim period the hospital is currently involved in a development plan to address some of those issues. Approved by: Date: Dr Rhona Mahony, MasterCEO

2 Postnatal 1 A layer of dust was visible on bedframes. A moderate layer of dust was visible on patients bedside tables. Grit was visible on surfaces in the corners of floors. Grime was encrusted in the wooden frames and sills of windows. A light layer of dust was visible on the surface of oxygen equipment. Solidified grime was encrusted on the wheels of the oxygen transporter. A heavy layer of dust was visible on surfaces inside storage cupboards. Splash marks were visible on the exterior surfaces of cupboard doors under the designated hand wash sink. A sticky residue was visible on surfaces inside and outside cupboard doors. A light to moderate layer of dust and sticky residue were visible on open shelving. Brown staining was visible on the surface of the sluice hopper. Revarnish of window sills currently being undertaken in areas identified A moderate layer of dust was present on the top surface of cupboards. A warning advisory sign such as cleaning in progress was not in position during cleaning Storage of cots and other equipment cluttering the corridor noted. Dust visible on surfaces of cots stored along the corridor. Staff reminded of operating procedures and supervision to ensure compliance Move to purpose build facility on campus with SVUH Trial of covering all stored cots commenced in Postnatal 1 HSE 2018 Clinical Midwifery 23 Result of trial to be reported to Committee

3 Floor covering in a shower was coming away from the wall at the join between the floor and the wall, hindering effective cleaning The covering behind the hand-wash sinks was coming away from the wall hindering Paint was missing from the surfaces of cupboard doors and these doors were chipped hindering effective cleaning (Clean Utility Room) The surface of shelving inside the cupboard under the wash hand sink was chipped (Dirty Utility Room) Large wheelie clincial waste storage bins were inappropriately stored in a stairwell adjacent to the post natal ward and outside the lift on the second floor. While the bins were locked the key to unlock them were in place adjacent to the bin. This finding poses a risk of access to unauthorised persons to potential hazardous clinical waste A moderate to heavy layer of dust was visible on the drawer supports of a resuscitation trolley and a moderate layer of dust was visible in the trolley drawers. The wheel areas of the resuscitation trolley were unclean. A heavy layer of dust was visible on the base of a vital sign equipment unit stand. Adhesive tape residue was found on the surface of the unit, hindering A light layer of dust was visible on the surface of oxygen equipment. Solidified grime was encrusted on the wheels of the oxygen transporter. A heavy layer of dust was visible on the underneath surface of a neonatal incubator, labeled decontaminated on 06 October 2013 in the nursery. The wheel areas were visibly unclean. There was a light layer of dust in the drawers underneath the incubator A moderate layer of dust was visible on an item of equipment for babies in the nursery. A daily signatory cleaning checklist attached to this equipment was not consistently completed on a daily basis Shower flooring to be repaired and re-glued to wall. Contractor has been contacted to repair flooring. Repaired Approved for upgrade, contractor appointed to replace cupboards Chipped shelving repaired Risk assessment carried out. Lock retrieval cord attached to key in combination lock box to be trialled in 2 Units. Deep cleaning performed. Equipment cleaning lists being monitored. Executive Management Team () CMM CMM CMM2 Trial to be reviewed by Hygiene Committee CMM2 Ongoing CMM2 Ongoing

4 as required by the hospital. The corridor was cluttered along one side due to storage of cots and other equipment, hindering A light layer of dust was visible on the surfaces of assessed cots stored along the corridor. The Authority was informed that these cots were ready for use. A medication trolley was observed in the baby care room which was locked but not secured to the wall in line with medication management best practice recommendations. Rust coloured staining was visible on the wheels of a trolley used to transport infant formula milk. There was a moderate layer of dust and a dried brown spillage on the surface of the trolley. There was a small amount of autoclave tape residue and adhesive tape residue, hindering effective cleaning Although there was a sign on a cupboard door stating please keep press locked, the cupboard was unlocked at the time of the assessment. Inappropriate items, including Christmas decorations, were stored in the clean utility room. Staining was visible on the inner surface of two patient washbowls. The washbowls were not inverted while being stored. A bed pan was not inverted while being stored. Urine catheter holders were stored on top of the patient washbowls and the bed pan. Access to sharps boxes stored by the sink used for washing patient equipment was obstructed by a dressing trolley. Rust coloured staining was visible on the wheel areas of the dressing trolley. During the assessment, the Authority observed that two pillowcases which were dropped on the floor as they were being removed from the clean linen cupboard were not put into a used linen bag. A used clinical dressing was in a tray in a patient shower area Cleaned equipment being covered. Addressed. Medication trolley locked and secured to the wall. CMM2 Ongoing CMM2 Monitor daily Trolley being replaced. CMM Cupboard now locked at all times. CMM2 Ongoing Alternative storage arrangements sourced for inappropriate items in clean utility room CMM2 Washbowls discarded and replaced. CMM2 Regular inspection of washbowls Training of staff. CMM2 Ongoing Hooks installed for correct storage. Facilities Department Trolley being replaced. New trolley ordered. CMM Staff training. CMM2 Ongoing spot checks Staff training CMM2 Ongoing

5 Antenatal Unit 3 A large amount of encrusted matter was visible in the corners and in the area under the footboard of the gridded metal mattress support on one of three beds assessed. A small space at the point where the floor covering and the wall border join was unclean. A light to moderate layer of dust was visible on some parts of the services conduit panelling above the beds in one patient room accommodating four beds. There were small amounts of sticky tape residue on surfaces of the services conduit panelling above some beds, hindering The back of a call bell assessed in a vacant patient bed space was soiled. The hand-wash sink in the clean utility room in Antenatal Unit 3 was unclean and a slight mould-like substance was visible behind the sink. The tile grouting directly behind the sink and the pipework to the taps located over the sink were unclean. Paint was missing from areas of the skirting boards at the base of the walls in patient areas, on window sills, boards and protective wooden boards fixed midway up the wall along the main ward corridor Small holes in the vinyl covering on a chair located in the centre of the 14 bedded ward hindering effective cleaning Vinyl surface tiles on the floor of a patient toilet that was assessed were cracked and worn, hindering effective cleaning Black mould like substance was visible in the area around the taps and the grid in the hand wash sink in a patient toilet Equipment was stored inappropriately in the linen storage room The door of the clean utility room was not secured The edges of open shelving were damaged exposing the interior surface, thus hindering effective cleaning (Clean Utility Areas identified will be re-painted following review by contractor. Project will commence as soon as access is available. Chair re-upholstered Flooring to be replaced Black substance removed and area resiliconed Equipment removed and new presses installed New lock to be fitted to door To be replaced with stainless steel shelving and presses. Supervision to Supervision to Supervision to Supervision to Supervision to Supervision to

6 Room) No sluice hopper available (Dirty Utility Room) The bases of two tiled walls were damaged and there was paint missing from the interior surfaces of the door and door frames (Dirty Utility Room) Not all patient equipment was stored safely. This presented a risk of injury to patients, for example, as standard, equipment was stored up the middle and along one side of the access corridor of the 14 bed ward. Equipment was also stored inappropriately in the designated clean storage room. There was sticky tape residue on the surface of one of the cardiotocography machines assessed, hindering effective cleaning. Some electrode fixation belts stored in a tray attached to the machine stand had evidence of contact gel residue on them, which, was not in line with best practice infection control methods. Four stacked boxes of intravenous fluids were stored directly on the floor, hindering The interior surface and the surface of the frame inside the door of a microwave oven in the clean utility room were unclean. A sticky residue was found on the exterior of the glass on the oven door. Two bags of clean unused canvas linen bags were inappropriately stored on top of the bedpan washer. Inappropriate items were stored in the linen room. This included five intravenous stands, three dressing trolleys (splash stains were visible on the surface of a trolley, while the footrest of a wheelchair was stored on the bottom shelf of one trolley), two oxygen cylinders, boxes of supplies on the floor, two baby cradles, Christmas decorations, two bed mattresses resting on the floor behind the door, and an item of clothing hanging on a hook. Heavy soiling was visible on mobile steps located in the linen room. Sluice hopper, sink and presses to be installed. Tiles to be replaced and door frame to be painted carried out. Every effort is being made to ensure that all equipment is stored as safely as possible when not in use, but there is limited storage for oversized mobile equipment in this ward and throughout the hospital CTG machines cleaned. New electrode fixation belts supplied and changed very regularly. Boxes removed, new storage units obtained and no items will be stored directly on the floor CMM2 Ongoing CMM2 Equipment cleaned and signed daily CMM2 Ongoing Microwave replaced CMM2 Storage hooks ordered CMM2 Appropriate storage cupboards installed. Christmas decorations removed from department. Deep cleaning performed. Old steps removed. Facilities Department CMM2 Team CMM2 Equipment cleaning lists being monitored

7 Standard 6: Hand Hygiene & Standard Precautions The Authority observed 20 hand hygiene opportunities in total. Of the 20 hand hygiene opportunities, only nine were taken. All nine were compliant with best practice hand hygiene technique. Despite annual hand hygiene training being mandatory for all staff, at the time of the assessment, records demonstrated that only 49% of staff had attended training in Competency Test for all Clinical, NursingMidwifery staff will be checked every two yearly by the link midwives. Hand Hygiene Training on HSE Land for Clinical staff is mandatory for all nursingmidwifery staff to complete. All clinical staff should be up-to-date in hand hygiene training (2012 and 2013) One annual un-announced audit to be completed in each ward by link midwives. Two National Hand Hygiene Audits are to be performed at the NMH within the time frames set out by HSE for National Hand hygiene audit results to be analysed and reported to the Senior Management Team and each area manager. Hand hygiene results and the improvement plans are to be reported and discussed in the Quality, Risk, Health and Safety Committee, Committee and Heads of Departments Meetings. All managers will receive quarterly report for all the staff in their departments who passed the hand hygiene training. These reports are available to Executive Management Team. New entries are created for Hand hygiene training sessions and HSE Land on-line training in the central hospital training system. Local sessions will be offered in some departments and to the senior doctors. Line managers to check their staff compliance with no barrier recommendations. ) Status On-going On-going On-going On-going On-going On-going On-going On-going On-going On-going