Infection Prevention & Control Update June 2019 - East of England Ambulance ...
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Infection Prevention
& Control Update
June 2019
Introduction
The first part of this IPC monthly update is an overview of the audit results from June
2019 and includes data on:
• Vehicle Cleanliness Audits
• Station and Premises Cleanliness Audits
• Uniform Policy Compliance
• IPC Practice – BBE, OE, PPE
• Quality Assurance (QA10) forms
• Quality assurance audit data- carried out by CEG and the IPC Team.
The IPC Monthly update reports on the 6 newly implement Sectors which incorporate
A&E, HART & PTS. For this reason, some of the reporting data from previous
months had been left as N/A due to the sectors not existing prior to this report.
The Audit Schedule and audit tools were reviewed and updated in the first quarter of
2019/20, using the data collected throughout the year and also information from all of
the work streams. Full details of the audit schedule, tools and requirements can be
found on East24. In brief the audit requirements for the 2019/20 audit year are:
Vehicle Audits:
• 75 % of all operational vehicles to be audited every month (every
vehicle must be audited at least once per quarter).
• All patient carrying vehicles should be Service cleaned every 12 weeks
and receive an Interim clean within every 48 hour period.
Station Audits:
• 100% of all operational stations to be audited monthly
Staff Audits:
• 15 Uniform compliance audits per management area monthly
• IPC Practice audits relating to the clinical staff’s knowledge of IPC
practices.
• QA10’s completed by operational management and mentors when
available.
Quality Assurance Audits:
• An IPC Auditor will be carrying out audits on Vehicles, Stations & staff
on a proactive basis opposed to a set schedule to enable a comparison
with local audits.
• Management area visits will be conducted by the auditors which will
include 6 monthly face to face meetings with the local management for
updates, training and tracking progress.
• CEG will be undertaking these audits throughout the year.
The second part of this update is an overview of reported IPC incidents, including
data on:
• Occupational exposure incidents
• Incidents which have potential to cause harm to patients, staff or the
publicPart 1: Overview of IPC audit results
Vehicle cleaning schedule compliance
12 Week Service Clean
The Trust has a 12 weekly service cleaning schedule for A&E, HART and PTS. This
clean incorporates the vehicle being removed from service for the equipment to be
removed and a full, in depth, clean of the equipment and vehicle structure is carried
out. Consumables and equipment will also be inspected for expiry date and damage
prior to being returned to the vehicle.
Table 1.1 below depicts the 6 sectors compliance with the 12 week vehicle cleaning
schedule and also the previous 2 months data for comparison.
Compliance 2 Compliance 1 Current month
Sector
months prior month prior compliance
HART 100% 100% 100%
Norfolk & Waveney 100% 83% 86%
Suffolk & North Essex 67% 65% 73%
Cambs & Peterborough 94% 81% 85%
South & Mid Essex 100% 99% 97%
Herts & West Essex 89% 85% 91%
MK, Beds & Luton 95% 95% 91%
Overall Trust Figures 90% 84% 87%
Table 1.1: Vehicle 12-week service clean compliance
(R.A.G Red-Interim Vehicle Clean (Overall cleaning schedule compliance)
The other element of the cleaning schedule that is reported on here is the ‘Interim
vehicle clean’. This clean should be conducted a minimum of every 48 hours on
patient carrying vehicles and every 96 hours on non-patient carrying vehicles. This
clean includes removing daily dirt and debris from the saloon, cab and exterior of the
vehicle using warm water and approved detergent.
The figures below are a measure of the respective areas average compliance with
cleaning schedule. A vehicle becomes 100% compliant with the cleaning schedule
on the day that it receives a full service clean. If the vehicle receives each
consecutive interim clean that it requires, it will remain 100% compliant. Each time
the vehicle misses an Interim clean the percentage of compliance for that vehicle is
reduced accordingly.
Table 1.3 below depicts the 6 sector’s overall compliance with the Interim vehicle
cleaning schedule and also the previous 2 months data for comparison.
Compliance 2 Compliance 1 Current month
Sector
months prior months prior compliance
HART 99% 95% 95%
Norfolk & Waveney 70% 69% 68%
Suffolk & North Essex 60% 60% 64%
Cambs & Peterborough 74% 71% 73%
South & Mid Essex 84% 82% 81%
Herts & West Essex 68% 79% 76%
MK, Beds & Luton 83% 82% 80%
Overall Trust Figures 72% 74% 74%
Table 1.3: Overall compliance per sector with the Interim cleaning schedule
(R.A.G Red-• North Essex and North Essex PTS remain to have the lowest compliance with the 48 hour interim
cleaning schedules but did increase very slightly to 49% each. However, there were some
improvements made over May and June which resulted in a 19% increase for the service
cleaning compliance for North Essex which finished June on 74%. North Essex PTS rose from
50% compliance to 54% for the 12 week service cleaning compliance. The priorities for the work
for North Essex Make Ready has insured that focus is solely on cleaning vehicles and they have
assistance from an additional member temporarily. There are other areas that are also not
compliant with either part of the cleaning schedules and in June recruitment has moved forward
for many additional Make Ready staff across the Trust which other the coming months should
have a significant positive impact on compliance with these schedules as staff capacity is
reported as the biggest factor to achieving this.
Vehicle Audits
There is a general flex of operational vehicles availability at any given time
throughout the month, for general repairs/ servicing etc. In most occasions where
vehicles are unavailable due to servicing/ repairs this is for a short period, however
on some occasions the nature of the repairs/ service can be such that vehicles are
unavailable for prolonged periods. Where this period is greater than three weeks we
exclude these vehicles from the reporting as they are not in operational use.
Sectors Incorporating PTS & HART
There were 636 vehicle audits submitted for this reporting period. The table below
depicts the percentage of audit forms submitted by each locality. Due to variation in
the numbers of vehicles in each locality during each month, and vehicle movements
throughout the Trust the IPC team is reliant on, and the responsibility lies with
the management teams for updating their vehicle numbers as they change. Each
quarter the IPC Team verify the sector vehicle lists for accuracy.
Last Report Last Report Current Current
Sector
Submission Compliance Submission Compliance
HART 100% 100% 100% 100%
Norfolk & Waveney 100% 97% 100% 97%
Suffolk & North Essex 88% 95% 91% 95%
Cambs & Peterborough 92% 90% 89% 92%
South & Mid Essex 97% 97% 86% 96%
Herts & West Essex 82% 97% 81% 96%
MK, Beds & Luton 98% 100% 90% 99%
Overall Trust Figures 92% 96% 89% 96%
Table 1.4: Vehicle audits submitted and Vehicle audit compliance
(Submissions R.A.G Red-Chart 1 below depicts the percentage of forms submitted for Trust vehicles.
100%
HART
90%
Norfolk & Waveney
Suffolk & North Essex
80%
Cambs & Peterborough
South & Mid Essex
70%
Herts & West Essex
MK, Beds & Luton
60%
Overall Trust Figures
April
May
June
Chart 1: Vehicle audit forms submitted per sector
Chart 2 below represents the average sector compliance with the submitted vehicle
audits.
100%
HART
Norfolk & Waveney
Suffolk & North Essex
90%
Cambs & Peterborough
South & Mid Essex
Herts & West Essex
MK, Beds & Luton
80%
Overall Trust Figures
April
May
June
Chart 2: Vehicle cleanliness compliance per sectorThe IPC vehicle audit is in 4 element groups including patient and non- patient areas.
Table 1.5 below depicts the compliance comparisons for patient and non-patient
areas for this month and last month.
Cab Saloon
Exterior Equipment
interior interior
checks check list
checks checks
Cambridgeshire & Peterborough – Jun 88% 90% 87% 95%
Cambridgeshire & Peterborough – May 78% 88% 85% 94%
HART – Jun 100% 100% 100% 100%
HART – May 100% 100% 100% 100%
Hertfordshire & West Essex - Jun 100% 98% 91% 97%
Hertfordshire & West Essex - May 99% 100% 94% 98%
MK, Bedfordshire & Luton - Jun 100% 100% 100% 99%
MK, Bedfordshire & Luton - May 100% 100% 100% 99%
Norfolk & Waveney - Jun 99% 96% 98% 97%
Norfolk & Waveney – May 94% 96% 94% 98%
South & Mid Essex - Jun 100% 99% 94% 95%
South & Mid Essex - May 100% 99% 95% 96%
Suffolk & North Essex - Jun 99% 95% 91% 97%
Suffolk & North Essex - May 99% 96% 91% 96%
Overall MAIN - Jun 98% 96% 93% 97%
Overall MAIN - May 95% 96% 93% 97%
Table 1.5: Sector Vehicle Compliance by Element Group
(R.A.G Red-Staff Audits
There are a variety of staff audits performed throughout the year on clinical staff,
these include:
• Uniform compliance
o These are reported monthly for all A&E, HART & PTS staff.
• QA10 compliance (includes Hand Hygiene at point of care)
o These are reported monthly for A&E & HART staff.
• IPC Practice Compliance (theory based audit for A&E and HART & PTS staff)
o These are conducted by the IPC Auditor and are reported monthly.
• Uniform compliance audits are carried out on all A&E, HART & PTS staff at
any point throughout their period of duty and consider the IPC related
elements of the Trust Uniform policy. A requirement of 15 Uniform audits per
management area is to be submitted monthly.
There was a total of 433 Uniform audits submitted during this reporting month.
Table 2.1 below depicts the Uniform audit submission and compliance for the report
month and the previous month.
Last Report Last Report Current Current
Sector
Submission Compliance Submission Compliance
HART 100% 100% 100% 100%
Norfolk & Waveney 100% 99% 100% 100%
Suffolk & North Essex 100% 98% 100% 97%
Cambs & Peterborough 100% 99% 100% 100%
South & Mid Essex 88% 100% 100% 100%
Herts & West Essex 99% 99% 98% 100%
MK, Beds & Luton 100% 100% 100% 100%
Overall Trust Figures 98% 99% 100% 99%
Table 2.1: Uniform audits submitted and uniform audit compliance
(Submissions R.A.G Red-Chart 3 below represents the Uniform audit submissions per sector.
100%
HART
Norfolk & Waveney
Suffolk & North Essex
90%
Cambs & Peterborough
South & Mid Essex
Herts & West Essex
80%
MK, Beds & Luton
April
May Overall Trust Figures
June
Chart 3: Uniform audit forms submitted per sector
Chart 4 below represents the Uniform audit compliance per sector.
100%
Norfolk & Waveney
Suffolk & North Essex
Cambs & Peterborough
South & Mid Essex
Herts & West Essex
MK, Beds & Luton
90% Overall Trust Figures
April
May
June
Chart 4: Uniform audit compliance per sector
The audit form is made up the following themes:
• Bare below the elbow compliance
o Compliance with Wrist watch policy
o No wearing wrist Jewellery
o No wearing of stoned rings
• Hair off collar/ tied back
• Nails (Short and free from acrylics and extensions)
16% of the uniform audits submitted were conducted during patient care
episodes. Also as the Trust has a policy which permits staff to wear a wrist watch
providing it is removed for hand hygiene, and decontaminated after each patient care
episode the percentage of staff audited who wear a fob watch has been highlightedas this may impact on the wrist watch policy compliance figure (as they will be N/A if
wearing a fob watch).
Chart 5 below relates to the themes of the Uniform audit. The Bare below elbows
element is an averaged result of the wrist watch, wrist jewellery and rings elements.
100%
90%
Bare Hair
below Nails
Rings
elbows Wrist
Wrist
jewellery
watch
Chart 5: Uniform audit theme compliance
QA10 Compliance Audits
The QA10 compliance audits cover IPC aspects of clinical procedures and carried
out at the point of care during operational observational ride outs with clinical staff.
Due to the high resource requirements versus output the numbers of these audits are
low. The IPC team is continuously reviewing this process and ways to increase the
numbers with the available resources.
The QA10 compliance audit measures compliance against IPC procedures during
patient care e.g. Aseptic Non-Touch Technique (ANTT), hand hygiene, uniform
compliance and post-patient decontamination
Table 2.2 below shows the quantity of QA10 audit submissions and the QA10
compliance for the report month and report previous.
Last Report Last Report Current Current
Sector
Quantity Compliance Quantity Compliance
HART 2 92% 2 100%
Norfolk & Waveney 6 100% 8 95%
Suffolk & North Essex 0 N/A 6 81%
Cambs & Peterborough 5 86% 3 100%
South & Mid Essex 0 N/A 2 100%
Herts & West Essex 0 N/A 1 100%
MK, Beds & Luton 5 100% 4 100%
Overall Trust Figures 18 95% 26 94%
Table 2.2: QA10 audit quantity and compliance
(Compliance R.A.G Red-Chart 6 below shows the compliance of the QA10 audits that were submitted.
100%
HART
90% Norfolk & Waveney
Suffolk & North Essex
Cambs & Peterborough
80% South & Mid Essex
Herts & West Essex
MK, Beds & Luton
70%
Overall Trust Figures
April
May
June
Chart 6: QA10 audit compliance
Chart 7 below shows the compliance of the QA10 audit sections by element.
Element compliance
100%
90%
80%
70%
ANTT Equipment Occupational Patient care Post patient Uniform
exposure episode episode compliance
Chart 7: QA10 audit compliance by element
• All elements of the QA10 audits completed achieved at least the minimum required compliance
and there were 3 cases where crew members were not wearing alcohol gel and one case where
hand hygiene was not performed prior to patient contact. The QA10 audits are going to be of
increased focus as the local management begin to increase the supervised ride outs they have
with their teams. Promotion of all of aspects is also disseminated by the IPC team during ride
outs as well as during discussions of practice audits.IPC Practice Compliance Audits
The IPC Practice compliance audits cover IPC aspects of hygiene prior, during and
post patient contact, uniform compliance, use of PPE and performance of IPC
practices. These carried out through discussion/ scenario reviews with clinical staff to
assess the knowledge base relating to IPC practice. These audits are carried out by
members of the IPC Team.
The IPC practice has now been separated into three separate sub audits, (Hand
Hygiene and Bare below the elbows), (PPE and occupational exposure) and (Patient
safety whistleblowing, safeguarding and security).
The IPC Practice compliance audit measures compliance against IPC procedures
during patient care.
• Hand hygiene,
• Bare below the elbows, which includes:
o Wearing of watches
o PPE
o Knowledge of occupational exposure procedures
Part of the audit includes the possibility to include a practical for hand hygiene
utilising a light box, however due to the availability of staff during these audits it is
often interrupted for emergency calls.
Table 2.3 below shows the quantity of IPC Practice audit submissions and the
Practice compliance for the report month and report previous.
Last Report Last Report Current Current
Sector
Quantity Compliance Quantity Compliance
HART 0 N/A 0 N/A
Norfolk & Waveney 0 N/A 10 98%
Suffolk & North Essex 0 N/A 4 99%
Cambs & Peterborough 4 85% 4 90%
South & Mid Essex 1 94% 6 82%
Herts & West Essex 3 84% 5 96%
MK, Beds & Luton 2 83% 4 94%
Overall Trust Figures 10 85% 34 91%
Table 2.3: IPC Practice audit quantity and compliance
(Compliance R.A.G Red-Chart 8.0 below shows the compliance of the IPC Practice audits that were
submitted.
100%
HART
90% Norfolk & Waveney
Suffolk & North Essex
Cambs & Peterborough
80% South & Mid Essex
Herts & West Essex
MK, Beds & Luton
70%
Overall Trust Figures
April
May
June
Chart 8: IPC Practice audit compliance
Chart 9 below shows the compliance of the IPC Practice audits by element.
100%
90%
80%
Bare below the elbows Hand Hygiene Needlestick/splash Personal protective
injury equipment
Chart 9: IPC Practice audit compliance by element.
• The IPC team has increased the focus further on staff practice audits throughout June. The
results of the practice audits that were conducted by the IPC team have shown that the 5
moments of hand hygiene and the available PPE (sleeve protectors and disposable suits) were
the lowest elements of knowledge. Some staff have not been fit tested for FFP3 masks with the
last 2 years and the hand hygiene questions highlighted that some staff were unable to state that
hands should be cleaned after contact with the patient surroundings and also prior to putting on
disposable gloves. The IPC team will be conducting practical hand washing technique
assessments utilising UV gel which is intended to promote the subject in a more engaging way.Station and Premises Cleanliness Audits
A&E, HART & PTS
80 EEAST premises were audited by local management in this reporting period. The
Trust has a comprehensive station cleanliness audit form in place and a standard
that 100% of all operational stations are to be audited monthly, this only applies to
stations where patient facing staff are based. This standard does not incorporate the
Trust emergency operations centres or locality offices which are audited and
reported on through the monthly contract cleaners report.
Table 3 below shows the quantity of Ambulance station audit submissions and the
compliance achieved for the report month and previous report.
Last Report Last Report Current Current
Sector
Submission Compliance Submission Compliance
HART 100% 99% 100% 99%
Norfolk & Waveney 100% 96% 100% 97%
Suffolk & North Essex 100% 98% 100% 96%
Cambs & Peterborough 100% 97% 100% 95%
South & Mid Essex 100% 97% 100% 99%
Herts & West Essex 95% 95% 75% 95%
MK, Beds & Luton 83% 99% 100% 100%
Overall Trust Figures 98% 97% 94% 97%
Table 3: Ambulance station audits submitted and audit compliance
(Submissions R.A.G Red-Chart 11 below shows the compliance of the Ambulance station audits.
100%
HART
Norfolk & Waveney
Suffolk & North Essex
Cambs & Peterborough
South & Mid Essex
Herts & West Essex
MK, Beds & Luton
90%
Overall Trust Figures
April
May
June
Chart 11: Ambulance station audit compliance
Table 3.2 below depicts sector comparisons by element for clinical and non-clinical areas for
this month.
Running
Washroo Handling Cleaning
medical Sharps
ms and and contractors
General equipment Dirty Kitchen and waste
locker disposal store /
(non- / utility area (non- manageme
rooms of linen cupboard
clinical) consumab (clinical) clinical) nt
(non- (non- (non-
les store (clinical)
clinical) clinical) clinical)
(clinical)
Cambs & Peterborough - May 97% 94% 98% 93% 85% 100% 97% 89%
Cambs & Peterborough - Apr 97% 89% 100% 98% 93% 100% 100% 85%
HART - May 100% 100% 100% 92% 100% 100% 100% 100%
HART - Apr 100% 100% 100% 100% 83% 0% 100% 100%
Herts & West Essex - May 100% 78% 93% 91% 91% 94% 100% 95%
Herts & West Essex - Apr 93% 81% 94% 100% 91% 84% 93% 93%
MK, Beds & Luton - May 100% 100% 100% 100% 100% 100% 100% 94%
MK, Beds& Luton - Apr 100% 100% 97% 100% 93% 100% 100% 93%
Norfolk & Waveney - May 96% 90% 97% 93% 93% 100% 98% 100%
Norfolk & Waveney - Apr 88% 89% 92% 100% 98% 100% 92% 95%
South & Mid Essex - May 100% 97% 98% 98% 100% 100% 95% 100%
South & Mid Essex - Apr 94% 92% 94% 98% 96% 100% 92% 96%
Suffolk & North Essex - May 85% 100% 92% 99% 96% 93% 97% 95%
Suffolk & North Essex - Apr 95% 97% 96% 100% 100% 93% 97% 100%
Overall MAIN - May 96% 93% 96% 96% 95% 98% 98% 97%
Overall MAIN - Apr 94% 91% 95% 99% 95% 97% 95% 94%
Table 5.2: Sector Vehicle Compliance by Element Group
(R.A.G Red-The audit form is grouped into five different themes:
• Information availability
• Procedural compliance, Cleaning Standards
• Clinical areas
• Waste management
o Clinical
o Sharps
o Domestic
The NPSA standard for risk areas is a cleanliness score of 85% for significant risk
areas and 95% for high risk areas.
The Trust has set a target of 95% for all areas.
Chart 12 shows the Ambulance station compliance per theme.
100%
90%
Cleaning Clinical Info Procedural Waste
Chart 12: Ambulance station audit compliance per theme
Table 3.3 below depicts Action Plans for non-compliance of Station cleanliness audits.
Opening Added in Closed in Closing
Management area Over due
balance period period balance
HART 0 2 2 1 0
Norfolk & Waveney 0 0 0 0 0
Suffolk & North Essex 0 4 0 2 4
Cambs & Peterborough 0 1 1 0 0
South & Mid Essex 0 8 4 1 4
Herts & West Essex 0 0 0 0 0
MK, Bedfordshire & Luton 0 2 0 1 2
Trust Total 0 17 7 5 10
Table 3.3: Ambulance station related actions balance per sector• The action balances seen in the table going to a point regularly raised with local managers at the
sector meetings to ensure that actions still open are current actions. These should be managed
regularly as an immediate response to audit non-compliance.
• As a Trust, the elements being raised as the lowest compliance are cleanliness of medical
equipment stores i.e. the flooring and storage boxes as well as cluttered kitchens and some
clinical waste issues. These elements did however score above 90% compliance.
Quality Assurance Auditing
A&E, HART & PTS
Quality Assurance Vehicle Audits
78 Vehicle quality assurance audits have been completed by the IPC team during
this reporting period. The QA vehicle audits comprise of either a full vehicle audit
which mirrors the same elements as the locally submitted vehicle audit and/or a
vehicle ‘Ready to Go Audit’ (RTG). The RTG audits are conducted by the IPC team
and are performed primarily at A & E departments to record compliance levels of the
patient treatment areas of DSA and PTS vehicles prior to further patient conveyance.
Table 4.1 below depicts the quantity and compliance of the vehicle audits conducted
by the IPC Team.
Last Report Last Report Current Current
Sector
Quantity Compliance Quantity Compliance
HART 0 N/A N/A
Norfolk & Waveney 4 71% 19 93%
Suffolk & North Essex 17 85% 8 91%
Cambs & Peterborough 7 88% 15 90%
South & Mid Essex 2 86% 14 92%
Herts & West Essex 15 79% 11 83%
MK, Beds & Luton 3 93% 11 88%
Overall Trust Figures 48 82% 78 90%
Table 4.1: Quality assurance vehicle audit quantity and compliance
(Compliance R.A.G Red-Chart 13 shows the compliance average per sector resulting from the IPC Teams
quality assurance vehicle audits.
100%
95%
HART
90% Norfolk & Waveney
85% Suffolk & North Essex
80% Cambs & Peterborough
75% South & Mid Essex
70% Herts & West Essex
MK, Beds & Luton
65%
Overall Trust Figures
April
May
June
Chart 13: Quality assurance vehicle compliance averages
• The quantities and distribution of quality assurance has been significantly increased in June.
The results show an overall increase of 8% in compliance found in June of 90% compared to the
82% Trust average found in May. The first sector that draws my attention is Hertfordshire and
West Essex, as this failed to achieve the minimum standard of 85% on average for the previous 3
months. A breakdown of some of the most prominent issues found in this area shows that
equipment and waste procedures are the lowest elements of compliance. Specifically trolleys
have been found to have missing belts as a fairly consistent issue. Other equipment issues of
the Herts and W Essex area are that many items of the IPC PPE are found to be missing
including aprons, sleeve protectors, eye protection and disposable suits. Waste and sharps
management has also failed to meet the standard in this area for a number of reasons including
waste being left on vehicles, unlabelled and incorrectly assembled sharps. The main cleanliness
issue found was regarding scoops being found unclean. Herts and W Essex has a low quantity of
AFA staff and has mainly VCOs which are not responsible for equipment, so during the service
cleans the equipment issues are not being picked up. I have gone into detail for Herts and West
Essex because overall the compliance of QA audits raises the highest concern, however the
whole Trust areas for improvement do raise the same issues of waste, patient safety (trolley
belts) and also missing IPC PPE. There were individual audit failures in other Trust areas and
action plans were assigned locally to rectify the issues. There were large audit discrepancies
found between the QA and local auditing with PTS Mid Cambs (24%) and PTS East Herts (31%)
being largest, however this was an average only over 3 audits so an increase in focus
throughout July in these areas will be conducted by the auditor to gain further insight.
Quality Assurance Uniform Audits
52 Uniform quality assurance audits have been completed by the IPC team during
this reporting period. The QA Uniform audits are conducted by members of the IPC
Team either on stations, at A&E departments or during ride outs. The Uniform audit
carried out is exactly the same as the locally submitted audit and the averages
percentages below can be used as a comparison for assurance.Table 4.2 below depicts the quantity and compliance of the Uniform audits conducted
by the IPC Team.
Last Report Last Report Current Current
Sector
Quantity Compliance Quantity Compliance
HART 0 N/A 0 N/A
Norfolk & Waveney 3 88% 12 91%
Suffolk & North Essex 2 88% 14 91%
Cambs & Peterborough 10 98% 9 100%
South & Mid Essex 1 100% 2 81%
Herts & West Essex 6 100% 5 100%
MK, Beds & Luton 3 96% 9 99%
Overall Trust Figures 25 96% 52 94%
Table 4.2: Quality assurance Uniform audit quantity and compliance
(Compliance R.A.G Red-The CEG (Community Engagement Group) have been accompanying the IPC
Auditors on some occasions and will soon begin auditing the stations alone with the
co-ordination of the IPC Team. As per the vehicle audits, any non-compliant will
result in an action being raised and emailed to the responsible party, in order for
them to rectify the issue and document the completion.
Table 4.3 below displays the quantity and compliance average of quality assurance
Ambulance station audits conducted for this period and last.
Last Report Last Report Current Current
Sector
Quantity Compliance Quantity Compliance
HART 1 94% 0 N/A
Norfolk & Waveney 0 N/A 0 N/A
Suffolk & North Essex 0 N/A 0 N/A
Cambs & Peterborough 3 85% 0 N/A
South & Mid Essex 0 N/A 0 N/A
Herts & West Essex 2 78% 1 83%
MK, Beds & Luton 0 N/A 1 95%
Overall Trust Figures 6 85% 2 89%
Table 4.3: Quality assurance Station audit quantity and compliance
(Compliance R.A.G Red-IPC Management area visits
The IPC management area visits are conducted predominantly by the IPC auditors.
The audit for each management area should include at least face to face meeting
with a member of the local management, which will usually be the AGM or SDM.
It is the intention of the IPC Team to conduct one of these visits 6 monthly to visit the
main station for the face to face twice and split the remaining satellite stations into
two and conduct the visit on those stations annually. Any concerns of outlying means
that the meeting could take place at that site instead.
The audit is split into sections including and IPC questionnaire/discussion to be had
between the auditor and local manager, which will include IPC knowledge, local audit
requirements, and the audit recording system training, local practice and issues.
The IPC auditor and local manager will then conduct a joint station audit which will
provide the area with their local result for that month meaning they will not have to
conduct a separate station audit for that particular site. This is also used as an
opportunity to gain continuity of auditing practice between the auditor and the local
manager and is an effective training method. It provides assurance that the
standards expected and being recorded are reasonably accurate.
The additional elements to this audit are also regarding internal and external estates
issues which may not be directly related to IPC, or be part of the standard station
audit. If any of the estate standards are not met or if repairs and safety issues are
raised, then an action will be raised to the local management to ensure that they
report this.
Table 5 shows the quantity of IPC management area visits that were carried out by
the IPC Team during the report month and previous month.
Last Report Report month
Sector
Quantity Quantity
HART 0 0
Norfolk & Waveney 6 2
Suffolk & North Essex 3 0
Cambs & Peterborough 0 0
South & Mid Essex 7 0
Herts & West Essex 2 0
MK, Beds & Luton 0 0
Overall Trust Figures 18 2
Table 5: Management area visits quantityCommunity Engagement Group
The IPC Team and Community Engagement Group (CEG) have been working
together and have begun a separate line of independent reporting by the CEG.
Training by the Trust IPC Practitioner and the IPC Auditors has been delivered to
each member of the volunteers.
This training has included;
• Induction (to explain to intended process and initial oversight of the auditing
system)
• Follow up training with the local auditor on one of the agreed designated
premise of responsibility.
• Continued joint auditing of all stations that the CEG member has agreed to
audit in future.
• Supervised audits conducted predominantly by the CEG member to ensure
competency.
• Audit recording system training to facilitate the independent uploading of data.
At this point, which some members are now at, the stations that the members have
been designated can be audited by each member potentially one or two audits per
member per month.
Below are the first lot of independently conducted audits by the members and the
IPC Team will continue to monitor and train the members for assurance of accuracy.
Table 6 shows the quantity and the average compliance of the station audits
conducted by the CEG members
Last Report Report
Last month
Sector month month Month
Quantity Compliance Quantity Compliance
HART 0 N/A N/A N/A
Norfolk & Waveney 0 N/A N/A N/A
Suffolk & North Essex 0 N/A N/A N/A
Cambs & Peterborough 2 90% 1 93%
South & Mid Essex 0 N/A N/A N/A
Herts & West Essex 2 90% 2 83%
MK, Beds & Luton 3 89% 2 82%
Overall Trust Figures 7 90% 5 84%
Table 6: CEG station audit quantity and compliance
(Compliance R.A.G Red-Part 2: Overview of IPC Related Hazards and Incidents
Incident Numbers
There have been some alterations to the questions within the Datix report which
specifically relate to IPC incidents, these have been included to act as a reminder to
staff regarding the procedures to follow and to ensure more details of the incident are
captured for reviewing the incidents.
There were 10 incidents reported on Datix relating to IPC.
Incident details
The 7 incidents relating to contaminated sharps injuries were:
• Whilst attending a patient for seizures, the colleague was attempting to gain
Intravenous access, staff member accidentally received a needle stick in their
right index finger. The correct aftercare procedure was followed. The wound
was bled, washed and dressed. A&E was attended, the incident was reported
to OH.
• Whilst assisting a colleague who was cannulating a patient the staff member
sustained a needle stick injury when they were disposing of a used cannula
and the safety cap came off. The correct after care procedure was followed.
The wound was bled, washed and dressed. A&E was attended where bloods
were taken. The incident was referred to OH for follow up. It was identified that
the cannula was faulty, this has been reported to supplies. Lessons learned
were the importance of disposing of sharps immediately after use and
avoiding double handling.
• A contaminated sharps injury was sustained whilst the member of staff was
disposing of a used vacutainer. The correct after care procedure was followed.
Bloods were taken. The incident was considered Low risk with OH follow up.
OH, have been contacted. It was identified that the incident occurred due to
the sharp’s container being full. Lessons were learned. The IPC Policy on the
correct usage of Sharps boxes was reviewed, it was emphasised that sharps
boxes must me locked when 2/3 full which should have alleviated the injury.
• A needlestick injury occurred when a member of Staff was getting into a car
and stepped onto a suture needle which punctured the boot and injured their
toe. The correct aftercare procedure was followed. The wound was bled,
washed and dressed. A&E was attended where bloods were taken. The
incident was considered Low risk with OH follow up. OH, have been
contacted.
• Whilst attending to a hypoglycaemic patient the staff member received a
needle stick injury from an uncapped insulin syringe that had been left of the
sofa. The correct aftercare procedure was followed. The wound was bled,washed and dressed. A&E was attended where the incident was considered
Low risk with OH follow up.
• Whilst transporting patient to hospital, staff member administered IM drug, the
vehicle jolted, and a contaminated sharp injury was sustained. The correct
aftercare procedure was followed. The wound be bled, washed & dressed.
A&E was attended where bloods were taken. The incident was considered as
Low risk with OH referral. OH, have been contacted.
• A needle stick injury was acquired when a member of staff picked up a
diabetic needle thinking that it was capped. The correct aftercare procedure
was followed. The wound was bled, washed and dressed. A&E was attended
where bloods were taken. The incident was considered low risk with OH follow
up.
The 1 incident relating to a splash injury was:
• Whilst holding the head of a patient during immobilisation the patient coughed
and spat which entered the eyes of the staff member. The correct after care
procedure was followed. A&E was attended where the eyes were irrigated,
and bloods were taken. The incident was considered high risk with OH follow-
up. High risk PEP supplied.
The 2 incidents relating to clean sharps injuries were:
• Whilst attending a patient with known Hep B, a clean sharps injury was
sustained whilst opening a glass vial. The correct aftercare procedure was
followed. The wound was bled, washed and dressed. The crew member
double gloved. A&E was attended where bloods were taken. As the needle
had not been in contact with the patient, the incident was considered low risk
with OH follow-up which has been done.
• A member of staff sustained a clean sharps injury when removing a clean
needle from a syringe. The correct aftercare procedure was followed. The
needle was disposed of correctly. The incident was discussed with a LOM
who advised to complete a datix, the injury was considered low risk as the
needle had not been in contact with the patient, it was identified that the
incident occurred due to wearing gloves that were too large.You can also read
