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Standard 3: Environment and Facilities Management No Opportunities for Improvement Action Required By Whom Timeframe Monitoring and evaluation Hygiene Services Manager Completed All rooms deep cleaned Ongoing monitoring involving regular hygiene audits DELIVERY WARD Environmental hygiene 1 2 3 Suboptimal environmental cleaning and Inconsistent adherence to standard infection prevention and control precautions Organic contamination on surfacesunder beds, Organic contamination on surfaceswall surfaces located within patient areas Substandard environmental hygiene observed in one delivery room which had been cleaned following a patient discharge Environmental contamination evident on the walls of the dirty utility room Adhesive tape residue present on a number of surfaces No evidence of deep cleaning, monitoring and assessment of hygiene of delivery rooms when vacant Schedule for deep cleaning of delivery rooms going forward put in place Hygiene Services Manager Adhesive residue tape removed and surfaces cleaned Hygiene Services Manager/ Maternity Care Assistants Monitored for compliance by regular daily inspections Household Supervisor Environment to be audited by senior staff/Independent persons periodically to ensure standards are maintained Hygiene Audit Committee/House Committee Insufficient dust control measures- dust noted on ledges, ventilation grills, floor edges and flooring underneath beds, skirting boards, and radiators All rooms deep cleaned Hygiene Services Manager Reusable spray bottles for detergent were not used appropriately in that bottles were reconstituted Spray bottles removed Monitored for compliance by regular inspections Completed Completed Completed Ongoing monitoring involving regular hygiene audits Completed Initial assessment done after introducing the Household Supervisor Infection Control Specialist Hygiene Services Comments Manager change successfully 4 A single mop head was used to clean up body fluid spillages in multiple rooms. Practice has ceased. Replaced by single-use mop head for every room Infection Control Specialist/ Hygiene Services Manager Completed 5 The condition and maintenance of surfaces, finishes and some furnishings in patient rooms including windows, wall paintwork, wall coverings, woodwork, wood finishes and a bed head were worn and poorly maintained and as such did not facilitate effective cleaning The longer term aspiration is to move to a modern purpose built facility. In the interim upgrade works will be initiated where feasible (in the context of risk & resource) to provide surfaces/materials that are more effectively cleaned and maintained. Engineering/EMT Works costed by end of March Implementation commenced and Will be an ongoing program for the year subject to availability of access. 6 Ceramic tiles had been painted over in one delivery room and some of this paintwork was flaking and damaged. Planning phase of interim works in progress . Flaking paint will be removed and Engineering/EMT March 2016 Surfaces and finishes on back stairwell corridor are degraded and do not facilitate effective cleaning Planning phase of interim works in progress Engineering/EMT March 2016 Implementation commenced and Will be an ongoing program for the year subject to availability of access. Implementation commenced and Will be an ongoing program for the year subject to availability of access. All DW beds have been replaced that allow for ease of cleaning CMM 3 Completed Beds replaced A cleaning schedule outlining clear lines of responsibility is currently in place( See CMM3 Completed 7 8 9 BEDS Design of patient beds does not facilitate effective cleaning or inspection of mattress cores Poor processes in place for cleaning of delivery beds with unclear lines of responsibility for staff more appropriate surfaces will be initiated subject to risk/resource analysis. Ongoing monitoring The building dates back to the early 1900’s and thus many of the surfaces and materials used do not meet modern design standards attachment) Cleaning consolidated and now conducted by one department Hygiene Services Manager RESOURCES 10 11 Cleaning resources allocated to delivery ward were insufficient. No allocation of rapid response cleaning team during periods of high activity No evidence of deep cleaning, monitoring and assessment of hygiene of delivery rooms when vacant Staffing resources increased Hygiene Services Manager Completed N/A Monitored for compliance by regular daily inspections Hygiene Services Manager/Househol d Supervisors Completed Ongoing monitoring Full Clean of all patient equipment to be completed by ward staff A cleaning schedule outlining clear lines of responsibility is currently in place( See attachment) Deep cleaning schedule now available and in operation Maternity Care Assistants Completed Patient Equipment Hygiene 12 Inadequate cleaning of patient equipment, monitoring equipment, theatre transport trolleys Stains observed on suction equipment on a resuscitaire Ultrasound gel residue on a handheld sonogram Organic contamination on surfacespatient equipment Dust on bedside observation monitoring equipment Stains on trolley holding a baby scales Stains on the base of a baby cot. Ongoing monitoring involving regular hygiene audits Clinical Midwife Manager 3 Clinical Midwife Managers Hygiene Audit Committee/House Committee Safe Injection Practice 13 Leftover intravenous medication in a tray at the bedside not discarded following patient discharge Multiple syringes containing reconstituted intravenous medications were insufficiently labelled and stacked in an unclean tray in a refrigerator in a delivery room. Labelling on some of the syringes indicated that the medications were drawn up several days prior to the inspection Improved labeling of anaesthetic medications with concentration, date and initials on labels. Regular reminders to NCHDs regarding safe drug labeling and now included in anaesthesia introductory pack and reminder on weekly anaesthesia schedule Emergency drug tray in theatre is discarded every morning (24hrs) this has been assigned to a member of the Anaesthesia team. Use of pre-filled syringes where possible on Dept of Anaesthesia Completed Ongoing monitoring the labour ward. 14 The refrigerator in which the medications were stored was unclean and ice build up was present indicating unmonitored temperature control. Decontamination Red stains present on interior surfaces of a trolley used to transport equipment for decontamination Transport trolley was unsecured and stored inappropriately on a communal corridor within delivery ward. Fetal blood sampling equipment brought to bedside in a holder containing multiple clean supplies for blood sampling Replaced. Cleaning schedule in place. CMM3 Completed A schedule of cleaning for HSSD transport trolleys is available and are cleaned when sent to HSSD CMM3 D/W HSSD Manager Completed Light Source Fetal Blood Sampling machine id transported to the patient bedside with only the necessary equipment to carry out that particular procedure CMM3 Completed The agreed and accepted solution to all of these issues is the move to a new purpose built modern facility. In the interim we propose to add some additional space (subject to planning/resource) to the delivery ward which will hopefully go towards improving some of these issues in the interim. Without a new modern build on another site these issues cannot be resolved up to modern standards and expectations but we hope these works will be improvements from the current situation HSE Infrastructure and activity levels 15 Suboptimal infrastructure does not facilitate effective cleaning: Operating theatre transport trolleys stored on delivery ward corridor Delivery ward rooms small in size relative to the amount of equipment deemed necessary in each room Delivery Ward corridors are narrow Ancillary rooms required for sterile equipment and medication storage, cleaning equipment management, decontamination and equipment storage and staff facilities absent, poorly designed or too small Not all patient rooms have ensuite/ Ongoing monitoring toilet/ shower facilities The design and finish of shared patient toilet/ showers did not facilitate effective cleaning Layout and use of Delivery Rooms 16 17 18 19 20 21 22 23 Five of ten delivery rooms linked meaning that delivery rooms were thoroughfare for staff, visitors, and waste and clean supply transportation Modern purpose built facility required on colocated site HSE Plan to reconfigure adjoined delivery rooms so that each room has its own access door. EMT One delivery room contained two beds Risk Assessment CMM3 Interim Works Commenced 2015 ongoing April 2016 EMT December 2016 This delivery room no longer has a multifunction purpose. CMM3 Completed Fridge removed CMM3 Completed Sterile supplies removed from Rooms 6 & 10 CMM3 Interim Works Commenced 2015 ongoing Sterile supplies have been removed CMM3 Completed Sinks now used for hand hygiene only CMM3 Completed Relocation of the dirty utilty. EMT/Engineering Interim Works Commenced 2015 ongoing Tissue sampling policy under review CMM3/Pathology Patient bed observed in lobby outside patient delivery rooms One delivery room used for multiple functionssterile supply storage, clean linen storage, antiseptic hand hygiene, preparation of procedure trolleys and preparation of cleaning of disinfection products Delivery room contained medication fridge, a blanket warming cabinet and extraneous patient equipment Sterile consumables were stored inappropriately on open shelves in delivery rooms in close proximity to clinical hand wash sinks or patient beds Two surgical scrub sinks adjacent to the sterile supply storage area in a delivery room which posed a risk of splashing and supply contamination Surgical scrub sinks use for purposes other than hand hygiene Interim Works Commenced 2015 ongoing Delivery Ward ‘Dirty’ Utility Room 24 Dirty utility room was small sized, poorly ventilated, used inappropriately for multiple functions Dirty utility used for the processing of tissue samples for pathology and storage of clinical specimens Clinical specimens were not packaged April 2016 25 26 or stored appropriately with evidence of spillage from specimen containers Dirty utility used for manual segregation of healthcare risk waste Dirty utility used for the processing of tissue samples for pathology and storage of clinical specimens Clinical specimens were not packaged or stored appropriately with evidence of spillage from specimen containers A spray hose attached to a water outlet over a sluice hopper was used to clean contaminated containers Planning phase of interim works being addressed. Risk Assessment in progress CMM3/Laboratory April 30th 2016 Spray hose removed replaced with tap attachment Engineering Mid March 2016 “dirty” utility to be refurbished/improved Engineering Interim Works Commenced 2015 ongoing Cleaning products have been removed to a designated store press Hygiene Services Manager Completed Pantry removed Engineering Dept Completed . 27 28 The hand wash sink in the dirty utility was small in size and is not in line with recommended specifications Access to the sink in the dirty utility is further restricted by a hose pipe used for detergent concentrate dilution Cleaning equipment and related products were inappropriately stored and managed in the dirty utility room Ward Pantry 29 The open environment of the pantry had the potential to compromise food safety. Waste Management 30 Clinical waste in uncovered and overfilled rigid bins which had been transported from the patient area or point of generation to the ‘dirty’ utility room The rigid bins used were then manually washed and reused. Biological tissue waste was not managed in line with a hospital policy which was displayed on a poster in the ‘dirty’ utility room. Biological tissue requiring disposal was packaged in black waste bags in uncovered rigid bins which were insufficiently labelled. Incontinence sheets were used inappropriately to absorb fluid leakage There was no designated waste storage room. Large mobile waste containers stored on back stairwell and have to be transported through the main corridor to the lift for removal All waste is now being segregated at source in each of the delivery rooms in keeping with best practice. Placenta storage and disposal of waste is now in line with hospital policy. CMM 3 Completed As part of interim works the storage of waste will be reviewed to see if there is any more appropriate location Cot removed All emergency exits are kept clear CMM3 Health & Safety Officer Completed & ongoing Reviewed on an ongoing basis The potential overcrowding issues in our NICU has been critically assessed through our NMH Risk Management Systems (DORMS) resulting in a corporate risk rating of “Low” due to existing controls which include sufficient O2 and other services for forty-six (46) occupants; continuous bed management and communications with other NMH units and external hospitals (as required) plus continuous, critical staff-consultant briefing Corporate Risk/EMT Completed As part of our DORMS risk management system, this risk is continuously monitored and evaluated Placenta disposal bins are now being lined with approved absorbant sheets. Placenta specimens are now stored in arigid closed box prior to being transported to the laboratory. NEONATAL INTENSIVE CARE UNIT CAPACITY 31 32 A fire exit was partially obstructed by a baby cot at the time of the inspection. Another cot was in close proximity to a clinical hand hygiene sink which may pose a risk of waterborne infection. Overcrowding in the Neonatal Intensive Care Unit was observed by Authorised Persons at the time of the October inspection. The NMH is also critically considering the use of additional special care unit of 8 x beds as part of a broader program of building infrastructure works. Re-inspection on 17 November 2015 DELIVERY WARD No Opportunities for Improvement Action Required By Whom Timeframe Monitoring and evaluation Environmental and patient equipment hygiene 33 Improvement in the management of patient trolleys is still required as the undercarriage of a patient transport trolley on the ward was unclean. Daily cleaning record of patient trolley is now in place outlining individuals responsibilities CMM 3 Completed Ongoing monitoring involving regular hygiene audits 34 Similar to the initial inspection, insufficient cleaning of a transport trolley for contaminated equipment was observed. The trolley was unsecured and inappropriately stored. In addition, the manner in which contaminated equipment was contained for transport did not fully protect the handler or the trolley interior from inadvertent contamination Cleaning: Trolley cleaned daily and electronic record kept in HSSD HSSD Manager Completed Weekly checks Storage of trolley in D/W: CMM3 Delivery Unit HSSD Manager Completed Daily checks Cleaning resource deficiencies were not fully addressed at the time of the re-inspection. A comprehensive follow up hygiene audit was not conducted to determine the progress made in the areas of concern. Additonal resource allocated Oct 2015 Hygiene Services Manager Hygiene Services Manager Completed Ongoing Review Completed Ongoing Review Ongoing monitoring 35 36 Containment of RIMD within trolley: Transparent lids have been attached to all boxes within transport trolley Delivery Unit hygiene audits are part of an internal audit hygiene plan Cleaning processes and the management of cleaning equipment 37 A cleaning specification for the Delivery Ward was not available at the time of the reinspection Completed and in place Hygiene Services Manager Completed 38 Improvements are required in the management of the cleanliness of the physical environment and in how the quality of the hygiene services are monitored and evaluated. Additional supervision to be recruited Hygiene Services Manager May 1st 2016 Delivery Ward ‘Dirty’ Utility Room 39 40 41 42 The spray hose attached to the water outlet of the sluice hopper remained in place The current process for obtaining placental tissue samples as described to inspectors needs to be revised as a priority. Restricted access to the clinical hand wash sink had not been addressed. Cleaning equipment was still stored inappropriately in the ‘dirty’ utility room Reusable spray bottles for detergent were still in use and were again stored and maintained inappropriately in the ‘dirty’ utility room as identified previously. Same as 26 Engineering Interim works – same as 25 March 2016 Same as 26 April 2016 Interim works Commenced 2015 EMT Mid 2016 Spray bottles removed Infection Control Specialist Completed Initial assessment done after introducing the change successfully Education on safe practice for labeling and storage of injectable medications to be included in twice yearly NCHD induction sessions Chief Pharmacist Completed Ongoing Completed Ongoing monitoring/spot checks Safe Injection Practice 43 No evidence of training, auditing or hospital wide dissemination of learning in relation to safe injection practice Midwifery Nursing 44 Intravenous anaesthetic medications being prepared in advance of emergency use in the delivery ward and in the theatre department Improved labeling of anaesthetic medications with concentration, date and initials on labels. Regular reminders to NCHDs regarding safe drug labeling and now included in anaesthesia introductory pack and reminder on weekly anaesthesia schedule Emergency drug tray in theatre is discarded every morning (24hrs) this has been assigned to a member of the Anaesthesia team. Use of pre-filled syringes where possible on the labour ward. Replaced. Cleaning schedule in place NEONATAL INTENSIVE CARE Practice Development Coordinator Dept of Anaesthetics/CMM 3 (NICU) 45 No dedicated cleaning staff allocated solely to the Neonatal Intensive Care Unit Dedicated cleaning staff are in place Hygiene Services Manager Completed OPERATING THEATRE DEPARTMENT 46 2 operating theatres were small in size with outdated facilities Infrastructural issue, need modern purpose built facility. Operating theatres are being reviewed and risk assessed to identify if there are any interim improvements. The size of these Theatres cannot be dealt with without a new modern build on another site. HSE Long Term Solution is to relocate to modern purpose built facility 47 Lack of storage space in the theatre complex Infrastructural issue, need modern purpose built facility. Operating theatres are being reviewed and risk assessed to identify if there are any interim improvements. The size of these OT’s cannot be dealt with without a new modern build on another site. HSE Long Term Solution is to relocate to modern purpose built facility 48 No designated cleaning equipment room Infrastructural issue, need modern purpose built facility. Operating theatres are being reviewed and risk assessed to identify if there are any interim improvements. The size of these OT’s cannot be dealt with without a new modern build on another site. HSE Long Term Solution is to relocate to modern purpose built facility 49 Inappropriate storage of equipment and supplies observed in operating theatres and corridors exacerbated by the excessive volume of sterile supplies stored there. Operating theatres are being reviewed and risk assessed to identify if there are any interim improvements. The size of these OT’s cannot be dealt with without a new modern build on another site. Alternative closed storage solutions currently being sourced. HSE Long Term Solution is to relocate to modern purpose built facility 50 The theatre complex was not self -contained which meant that the recovery room was located outside the operating theatre Infrastructural issue, need modern purpose built facility. Operating theatres are being reviewed and HSE Long Term Solution is to relocate to complex risk assessed to identify if there are any interim improvements. The size of these OT’s cannot be dealt with without a new modern build on another site. modern purpose built facility 51 A scrub room was shared between theatres 1 and 2. The space allocated in the scrub room was limited and did not comply with recommended specifications. None - the current design predates current recommendations and guidelines and cannot be altered due to infrastructural and envelope limits. The loss of OT 2 would be required to enlarge the scrub. Operating theatres are being reviewed and risk assessed to identify if there are any interim improvements. The size of these OT’s cannot be dealt with without a new modern build on another site. HSE Long Term Solution is to relocate to modern purpose built facility 52 The door leading from the corridor to the scrub room was left open on two occasions during the inspection CMM 3 Engineering Completed 53 The door of the sterile set up room was open at the time of the inspection CMM 3 Engineering Completed Monitor daily 54 Light levels of dust were observed on some surfaces in the sterile set up room with dated infrastructure of the room being a likely contributing factor to the dust levels observed Communicated to staff however the door being open does not impact the operation of the HVAC as it pressure relieves to the corridor as part of its normal operation. Communicate issue to staff for immediate mitigation. Door closer to be fitted by Engineering. Staffing resources under review. Need additional cleaning hours/household staff for the department Hygiene Services Manager May 1st 2016 Quarterly Departmental Hygiene Audit Specify recommendati ons as standards are not retrospective. This design should be considered in keeping with US DVA 2016 in the absence of any STANDARD, GUIDELINE or Specification being identified. CMM3 Theatre Weekly spot checks 55 Small areas of damage to the floor in theatre 3 which could impact on cleaning Repairs will be initiated to floor covers and wood finishes. Engineering Mid March 2016 Quarterly Departmental Hygiene Audit 56 Wood finish on doors and door frames leading from the main corridor to operating theatres 1 Repairs will be initiated to floor covers Engineering December 2016 Quarterly Departmental and 2 was damaged and wood finishes. 57 The double doors of operating theatre 2 when closed did not seal the doorway This is as per the design intent to maintain air changes and pressures. Design circa 1992. A revalidation will be conducted to ensure performance to design intent. Compliant with HTM 2025 Engineering 58 Current infrastructure and design of the theatre complex does not meet international best practice guidelines for operating theatre infrastructure Move to co-located site HSE 59 Inconsistent management of spillages of blood Correct management of blood and bodily fluid spillages addressed with theatre clinical and non clinical staff. CMM3 Theatre Review of local cleaning policy and cleaning/disinfecting products carried out. 60 Pre-prepared syringes of anaesthetic intravenous medications were stored on a tray on the anaesthetic trolley in an operating room Due to the emergent nature of obstetric anaesthesia and anaestheisa for other procedures it is common practice to have a set of emergency drugs at the ready to deal with acute physiological and pathophysiological changes that can occur during the peri-operative period both for elective and emergency cases. Drugs are prepared just before each case in advance of Hygiene Audit Long Term Solution is to relocate to modern purpose built facility Engineering will revalidate to HTM 2025 of 1994 OTs 1& 2 and HTM 03-01 B OT 3 to ensure performances annually Specify international design standards and areas of noncompliance would be helpful in addressing inferred nonconformance s. Completed Ongoing monitoring Completed Weekly spot checks Infection Control Household Supervisor Director of Anaesthetics CMM3 Theatre the patient entering the theatre. Where possible individual preloaded sterile have been sourced. Communicated to Anaesthetic NCHD and Incorporated a part of the induction programme, including: 1. Drug syringe to be labeled dated and initialed 2. No additives allowed 3. Caps placed on end of syringe 4. Drug to be discarded after 24hrs These drugs would be for single patient use only. Standard 6: Hand Hygiene Hand Hygiene Facility No Opportunities for Improvement Action Required By Whom Timeframe Interim Works Commenced 2015 ongoing Monitoring and evaluation System Change 61 Clinical hand wash sinks observed in the Delivery Ward and some of those in the Theatre Department did not comply with HBN 00-10.11 Room 1 has a compliant HBN 00-10 C WHB. No WHB upgrade works have been undertaken in the LDU since the early 1990's from records and thus this Guideline would not apply as was first published late 2013 / early 2014. Predating Guideline HTM 64 (Sanitary Assemblies) of 1995 & 2006 would also not apply. Upgrade works are being considered as part of interim development works. EMT 62 A room used essentially as a ‘clean’ utility This room may be considered for a Key Stakeholders This appears in error as there is no HBN 0010.11 I may perhaps be assumed that the reference is to HBN 0010 C Sanitary Assemblies of 2013/14? 63 room in the Delivery Ward did not have a clinical hand wash sink. WHB by the EMT et al as part of interim works in the interim a risk assessment will be undertaken by stakeholders to use Alco Gel as an alternative. LDU, IPC etc. Scrub sinks in the Delivery Ward were not designated for hand hygiene only in line with best practice guidelines. The location of scrub sinks in the Delivery Ward did not facilitate easy access. Links with point 65 above. Engineering This QIP is to address non-compliance of hand hygiene sink in room 3. Sterile supply storage and cleaning equipments are removed from this room and access to the sink is enhanced. Sink is only used for hand hygiene. Infection Control Specialist Completed It would be useful to identify the best practice guidelines and why/where nonconformance s exist to these BPG.
