DRAFT

Quality, Standards and Effectiveness Directorate

Infection Prevention and Control Audit Report

(General Practice)

Audits undertaken between September 2008-November 2008 by

Patricia Cross/Andrea Caldwell

Community Infection Prevention and Control Nurses

Compiled by:

Anne Warburton

Quality Facilitator

North Lancashire Teaching Primary Care Trust

Key: this page to be removed before issue to practices

Contents

Introduction

The Department of Health is firmly committed to reducing healthcare associated infections (HCAI). To bring about an improvement in infection prevention practice it is important that measures known to be effective in reducing infection are rigorously and consistently applied, and are embedded into everyday practice. The Health Act 2006: Code of Practice for the prevention and control of healthcare associated infections indicates that compliance with audit programmes will provide assurance that demonstrates infection prevention and control is an integral part of the practice culture.

Aim

The aim of this audit programme was to give a clear indication of the standards of infection prevention and control and the environment within the institution. The audit tools used have been specifically designed by the Infection Control Nurses Association to monitor infection prevention and control within community settings.

Method

Community Infection Prevention and Control Nurses Patricia Cross and Andrea Caldwell carried out the audits. The audit programme started in September 2008 and was completed in December 2008.

All 39 GP practices within the geographical area of NHS North Lancs were invited to take part. 1 Practice declined due to the recent death of a partner and subsequent building changes that were envisaged to last approximately 3 months.

The Infection Prevention Control Nurses visited 38 practices and14 branch practices and were assisted by practice nurses and practice managers on all visits. Once the information had been analysed each practice was then sent a report that highlighted the issues that need to be addressed. Other supporting literature e.g. policies, posters and national guidance was also sent. Each practice was also asked to submit a detailed action plan that demonstrated how changes could be implemented.

This audit programme has examined the following standards:

Environment : The environment will be maintained appropriately to reduce the risk of cross infection.

Hand Hygiene: Hands will be decontaminated correctly and in a timely manner using a cleansing agent to reduce the risk of cross infection.

Personal and Protective Equipment: Personal protective equipment is available and is used appropriately to reduce the risk of cross infection.

Sharps Handling and Disposal: Sharps/ needlestick injuries, bites and splashes involving blood or other body fluids are managed in away that reduces the risk of injury or infection.

Vaccine transport and storage: Vaccines are stored and transported safely.

Summary of Results

Summary of findings

The areas highlighted for attention and contributed to poor compliance with the standards were:

Environment

Hand hygiene

Sharps handling and disposal

Personal Protective Equipment (PPE)

Vaccine Usage

Fridge used for items other than vaccines.

The top of the fridge was used as a storage area.

Some fridges were over stocked.

Conclusion and recommendations

As this was the first time that an Infection Prevention and Control audit programme had been undertaken within GP practices throughout the geographical area of NHS North Lancs no comparison can be made.

The Infection Prevention and Control Nurses were made welcome at all practices and it was reassuring to see that there was a keenness to make changes and raise standards.

During each audit verbal advice was given and this was followed up with an individual report to each practice that highlighted the areas that need to be improved.

Environment

To help improve cleaning standards within the practices each practice was given an audit tool to assist with the monitoring of cleanliness standards and information was also provided on detergent wipes which would help with the cleaning of equipment and the environment.

It was also recommended that when each practice undergoes a process of refurbishment they consult the IPC nurses who would be able to advise on room design, sink design, floorings and fabric covering for furniture.

It was also suggested that all linen (hand towels, sheets and pillow cases) be removed and blue roll and wipeable pillowcases used instead.

Lastly it was recommended that curtains be laundered on a regular basis.

Hand Hygiene

To help improve standards of hand hygiene the IPC nurses have provided posters, which should be displayed at all hand wash sinks. Each practice has also been offered hand hygiene training sessions and information on NPSA approved hand hygiene products.

Practices were also reminded that sink areas should be kept free from clutter and that nail brushes are single use items.

Sharps handling and disposal

To ensure sharp safety all Practices were advised that any containers that are not bar coded must be labelled with room name and date prior to collection. To ensure a safe position wherever possible containers should be wall mounted with appropriate brackets.

First aid posters have been provided to all Practices that did not have one on display.

Personal Protective Equipment

To help reduce clutter at the sink areas it was recommended that gloves are stored in cupboards or on trolleys a way from an area where they could get splashed and damp.

It was also recommended that each Practice have a supply of face masks which could be used if there was a risk of body fluid splashing and would also be part of pandemic flu planning.

Vaccine Usage

It was recommended that vaccine fridges store vaccines only, and are stocked to appropriate levels.

Action Plan

As part of the Audit Cycle, it is expected that an action plan is produced by each Practice outlining the recommendations, how this will be achieved, by whom and in what time frame. So far the IPC Nurses have received 27 action plans, which illustrate how the recommendations will be met. A polite reminder has been sent to the Practices where action plans are outstanding.

Each Practice has been provided with a copy of the audit tools and encouraged to carry out the audit on a 3-6 monthly basis. It is envisaged that this will help to maintain and hopefully improve standards and reduce the number of Practices receiving a minimally compliant score.

It is anticipated that the Infection Prevention and Control Nurses will re-audit the Practices on a bi- annual basis.

Overall Scores

Overall scores were calculated for each standard as follows:

For each section of the audit, the percentage of `yes' responses was calculated as

Number of `yes' responses x 100

`yes' responses + `no' responses

This calculation therefore excluded N/A responses, where the question was not applicable.

The following table shows overall performance based on the mean average scores of all the standards.

Overall Individual Scores

The following table shows which practices achieved overall Compliance with the standards (75% - 100%).

The following table shows which practices achieved Minimal Compliance with the standards (0% - 74%).

Practices which achieved Partial Compliance have been audited but have not been shown.

Put number of practices here

Key:

Environment:

Standard: The environment will be maintained appropriately to reduce the risk of cross infection.

Hand Hygiene

Standard: Hands will be decontaminated correctly and in a timely manner using a cleansing agent to reduce the risk of cross infection.

Personal and Protective Equipment

Standard: Personal protective equipment is available and is used appropriately to reduce the risk of cross infection.

Sharps Handling and Disposal

Standard: Sharps/ needlestick injuries, bites and splashes involving blood or other body fluids are managed in a away that reduces the risk of injury or infection.

Vaccine Transport and Storage

Standard: Vaccines are stored and transported safely

NB: One practice does not have vaccine facilities and was not audited in this standard.

Appendix 1 - Audit Tool

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