Published on 4 April 2023

NSQHS Std 3: INFECTION PREVENTION BULLETIN March I 2023

  • Introducing the Infection Prevention 'Sensational 7'

    The ‘Sensational 7’ team are multi-disciplinary leads brought together to support the organisation and the WH Infection Prevention Committee be aware of and continuously improve WH practice against NSQHS Standard 3 requirements.

    The Sensational 7 Team is:

    Team Lead: Monique Sammut DONM

    Co-Chair: Dr Adrian Tramontana ID Consultant

    Quality Lead: Rachael Duff

    Education lead: Chelsea Cornford

    Allied Health Lead: Casie Barrette

    Infection Prevention Leads: Maureen Canning Operations Manager IP; Richard Bartolo Principle IP Clinic Nurse Consultant

  • Do you have any questions?

    For any queries about Infection Prevention you’d like to direct to the NSQHS Std 3 Sensational 7 or others, please contact BestCare@wh.org.au

     

  • Like to know more about Accreditation Readiness?

    Visit our Live Best Care site at  https://westerly.wh.org.au/livebestcare/  or use the following QR Code to find out more about NSQHS Standard Readiness.

From Monique

As part of Accreditation Readiness activity, a NSQHS Standard of the Fortnight initiative is being introduced. This involves a focus on one Standard per fortnight, with communications and walkarounds to help staff be aware of how Best Care at Western Health reflects this Standard, to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.

We are excited that NSQHS Standard 3: Infection Prevention is to be the focus of the first Standard of the fortnight. This will run from Monday 27 March to Friday 7 April. Look out for friendly Best Care Co-ordinators, Sensational 7  team  members and other staff who will pop into clinical areas/departments to talk with you about Infection Prevention.

The Preventing and Controlling Healthcare-Associated Infection Standard aims to support reducing the risk of patients getting preventable healthcare-associated infections, manage infections effectively if they occur, and limit the development of antimicrobial resistance.

The Preventing and Controlling Healthcare-Associated Infection Standard supports Western Health to provide Safe Care.

Western Health’s comprehensive infection prevention and control program draws upon requirements of this Standard and supports the monitoring, prevention and control of healthcare-associated infection. Procedures and strategies to help reduce the risk of infection include:

  • Infection prevention and control strategies, such as hand hygiene, use of personal protective equipment (PPE), cleaning, staff immunisation and invasive device management
  • Strategic patient placement and accurate recording of patient records on admission
  • Vigorous antimicrobial stewardship to control inappropriate use of antibiotics and deliver ongoing education and training
  • Audit of the hospital environment cleaning level to maintain accepted quality

Western Health’s infection prevention program is supported by our wonderful Infection Team Team run by Maureen Canning and Richard Bartolo who have worked extra hard over the COVID-19 period to support our patients, staff and visitors to remain safe. We are very proud of the way all staff at Western Health have contributed to a COVID safe environment and continue with the everyday activity that supports keeping our patients safe from infection.

Our new ‘Sensational 7’ team has brought together nursing, medical, allied health, education, quality and infection prevention expertise to support our ongoing compliance with NSQHS Std 3. We are working closely with Western Health’s Infection Prevention Committee to ensure we are continually monitoring, reviewing and improving our infection prevention and control practices.

The good news is we are already providing Best Care and living up to the requirements of NSQHS Std 3 on Infection Prevention in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This year’s Survey is simply a chance to show once again how well we support reducing the risk of patients getting preventable healthcare-associated infections.

Please continue reading to find out more about our infection prevention strategies, achievements and opportunities for improvement, as well as resources to help you be Accreditation Ready for NSQHS Std 3.

 

Monique Sammut

NSQHS Std 3 ‘Sensational 7’ Team Lead

Director of Nursing Sunbury  IP, CSSC, WPHU & COVID Response

 

Resource Centre

The following resources have been put together to support staff to be aware of the NSQHS Infection Prevention Standard and Accreditation Ready for Survey against this Standard:

 

Patient Story

The Infection Prevention Committee (IPC) consumer representative actively reviews and advises the IPC on issues related to providing information to consumers and carers.

The IPC consumer provided feedback about a complaint she received from her national patient advocate role on the condition of a bathroom at Sunshine Hospital which had damaged floor vinyl and poor cleaning standards.

This resulted in an internal investigation after which the affected bathrooms were rectified. This was fed back by the consumer representative to the family member involved who initially raised the concerns. The family member was greatly appreciative of the prompt action.

 

Improvement Initiatives

There are multiple improvement initiatives underway to improve the prevention and management of infection. Do you know about these?

  • An online Infection Prevention Performance Dashboard is under development
  • An online Antimicrobial Stewardship Performance Dashboard is also under development
  • We are investigating automatic alerts regarding patient who have travelled overseas or been in hospital in the last 12 months
  • Engineering have been following up preventative maintenance program opportunities for improvement
  • New procedures being introduced to address biofilm build up in waste drains
  • A SAB Task Force has just commenced

 

Achievements and Opportunities

We are proud of…

  • The way all staff at Western Health have contributed to a COVID safe environment
  • Staff continuing with the everyday activity that supports keeping our patients safe from infection
  • WH continuing to benchmark highly with other Australian healthcare services and national aggregate for hand hygiene compliance
  • WH achieving a total of 94.8% vaccinated (A/B/C categories) for influenza in 2022, above the VICNISS aggregate
  • Meeting all 2021-22 Statement of Priority KPIs for surgical site infections surveillance with nil significant infection rates, and achieving zero central line infections in our ICUs
  • The installation of RO (Reverse Osmosis) water in CSSD at Bacchus Marsh/Melton, Sunshine and Williamstown

We are looking forward to…

  • The launch of our annual Flu Vaccination Program in the last week of April 2023
  • WH staff being able to access infection prevention data from centralised, online dashboards
  • The installation of a computerised tracking system of resuable medical devices (RMDs) for Bacchus Marsh CSSD by year end

Our focus continues on…

  • Addressing our fluctuating rate of SAB infections
  • Addressing the infection risk associated with identified build up of biofilm
  • Reviewing laundry/linen practices/storage to minimise associated risk of infection
  • Reprocessing ultrasound probes and high level disinfection after use during invasive procedures
  • Improving timely infectious diseases screening

 

Key Messages

 

Data Analysis

  

Key Messages
Biofilm in Clinical          Hand Basins Auditing tells there is high and higher level biofilm growth identified in up to 10% of clinical hand basins in flagged areas of concern at Sunshine Hospital Let’s reduce the risk of biofilm associated hospital acquired infections by:

  • not discarding fluids such as IV fluids, Dialysate, TPN, NGT feeds and aspirates, contaminated water from wash bowls, mouth-care etc into clinical hand basins. These should be discarded in the dirty utility room.
  • not discarding fluids such as beverages. These should be discarded in the kitchenettes.
  • not storing equipment on clinical hand basins (likely to become contaminated by splash)
Healthcare-associated bacteraemia

 

 The numbers of Staph.aureus Bacteraemia infections (Healthcare-associated) continue to fluctuate, with a current year to date result of 0.8/10,000 OBDs, above the target of 0.7

 

 Let’s reduce the risk of line infections by:

  • Scrubbing the hub for 15 seconds and allowing to dry prior to accessing any device
  • Only inserting a device if it is needed. Hesitate before you cannulate
  • Using a non-touch technique during insertion
  • Avoiding areas of flexion unless clinically necessary such as cubital fossa, and re-site cubital fossa IVs as soon as appropriate
  • Removing IVCs as soon as a device is no longer required
Hand Hygiene Hand Hygiene audit results are showing good results of almost 90% which is above Department of Health target Let’s continue to reduce the risk of hospital acquired infections by:

  • Having hand hygiene available at point of care
  • Performing the 5 Moments of hand hygiene
  • Cleaning hands and changing gloves that have become contaminated
Needlestick Injuries We are still recording too many avoidable sharps injuries Let’s reduce the risk of needle stick injuries by:

  • Not recapping needles
  • Using safety devices correctly
  • Not using patient owned insulin pens
  • Wearing eye protection
COVID Ongoing vigilance is required to ensure there are no delays in the use of respiratory based precautions Let’s reduce the risk of patient acquired COVID by:

  • Introducing respiratory based precautions in a timely fashion
  • Completing COVID risk assessment at each shift
Linen Handling Observational auditing of linen handling show trolleys are occasionally uncovered when not in use and staff are touching linen without changing gloves Let’s reduce the risk of infection associated with handling of linen by:

  • Covering linen trolleys when not in use
  • Performing hand hygiene before accessing linen from trolleys
Infectious Disease Screening Preadmission Screening Tool Audit data show an 80% completion rate but significant variance between areas and delays in completion Let’s reduce the risk of hospital infections to others by:

  • Completing patient infectious risk screening within 2 hours of admission to wards
Ultrasound Probe Cleaning There are identified process deficits in the management of ultrasound transducers Let’s reduce the risk of infection from ultrasound transducers by:

  • Ensuring appropriate cleaning and disinfection
  • Ensuring appropriate patient tracking of probe use
Staff Immunisation Nearly 95% of our staff had a flu vaccination last year – a great result! Let’s keep reducing the risk of patients and staff acquiring influenza by:

  • Keeping up-to-date with seasonal influenza vaccine