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  • in reply to: Hand Hygiene auditing in the operating room #70683
    SDH Manager
    Participant

    Author:
    SDH Manager

    Email:
    manager@SOUTHPORTDAYHOSPITAL.COM.AU

    Organisation:

    State:

    HI Maree

    We are only a very small day hospital and I have always audited in the operating theatre (our theatre staff & anaesthetists), as well as our PACU. HHA are aware of this and have never said anything to me, so I will continue to do it.

    Personally, I think theatre should be audited. We have Alcoholic rubs placed in theatre for staff to use. The circulating nurse is touching the patient and then touching other items in the theatre, as well the anaesthetist and anaesthetic nurse are also touching the patient and putting in IVs and doing other invasive procedures, so why shouldnt they be audited? We are also planning on doing surgical scrub audits and hand hygiene observational audits on our surgeons, they are statistically the worst offenders!

    Regards

    Tina Owens, RN

    Clinical Manager

    Southport Day Hospital

    Tel: (07) 5555 7800 / Fax: (07) 55557801

    Mb: 0419 026 091

    Email: manager@southportdayhospital.com.au

    From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Maree Sommerville
    Sent: Wednesday, 11 December 2013 7:40 AM
    To: AICALIST@AICALIST.ORG.AU
    Subject: Hand Hygiene auditing in the operating room

    Dear all,

    I am interested to know if anyone does HH auditing in the operating room.

    It is my intention to do some ad hoc audits in the New Year.

    I have already done a preliminary assessment and the biggest challenge is defining the areas (patient care zone or health care zone).

    The HH audit tool currently in use easily suits a ward but will it suit this type of critical care area.

    Has anyone audited this area?

    If so, how did you define the zones for each group (anaesthetic team / surgical team / theatre tech)?

    If any of you have audited this area, did you adapt the current HHA tool or did you use another?

    Look forward to your responses.

    Maree

    Maree Sommerville

    Infection Control Coordinator

    Mercy Hospital for Women

    163 Studley Road

    Heidelberg 3084

    Phone: 8458 4759

    Mob: 0408 789 798

    Fax: 8458 4751

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    SDH Manager
    Participant

    Author:
    SDH Manager

    Email:
    manager@SOUTHPORTDAYHOSPITAL.COM.AU

    Organisation:

    State:

    Hi Brenda,

    We didnt seem to have any issues with accreditation concerning our processes, we simply have medtrax record books to keep track of our sterilisation processes. We also do internal audits.

    However, if you need any audit tools, you can go to the QLD Health site. I note they actually havent got any up for Standard 3 yet, but should very soon, so just keep an eye on this site, if you havent already discovered it.

    http://www.health.qld.gov.au/psq/safetyand quality/nsqhss-audit-tools.asp

    Regards

    Tina Owens, RN

    Clinical Manager

    Southport Day Hospital

    Tel: (07) 5555 7800 / Fax: (07) 55557801

    Mb: 0419 026 091

    Email: manager@southportdayhospital.com.au

    From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Brenda Anderson
    Sent: Thursday, 15 August 2013 12:38 PM
    To: AICALIST@AICALIST.ORG.AU
    Subject: AS/NZS 4187 Section 7 re monitoring of sterilizers and associated equipment

    I am interested to know how people interpret the statement in AS/NZS 4187:2003 Section 7.1

    All stages of the sterilization process shall be developed and documented to ensure that the items can be sterilized.

    The process shall be reliably reproduced and routinely monitored to the desired probability of a non sterile item.

    Routinely monitored (is where I want input) I realize each step will be written up in a policy/procedure manual- but how is the procedure monitored to know the policy is being followed.

    All stages are then listed:

    (a) cleaning – how is manual cleaning monitored??

    (b) Inspection how is the inspection process monitored??

    (c) Assembly How is the assembly process monitored??

    Etc.. goes to (k) validation of the process

    I realize that the sterilizers and washer/ disinfectors have monitoring mechanisms in place (i.e bowie dick, soil tests etc and these are monitoring the performance of the machines) I am interested in the process indicators for the manual components of the process?

    This is a theme of accreditation standard 3.3.16.1 quality control systems to monitor each stage of handling or items requiring reprocessing.

    I would appreciate any comments or even better audit tools

    Regards

    Brenda Anderson

    Mrs. Brenda Anderson
    Regional Infection Control Consultant
    Hume Region Infection Control Resource and Consulting Service
    Northeast Health Wangaratta

    Northeast Health Wangaratta
    Green St, Wangaratta, VIC 3677

    Brenda.Anderson@hume.org.au
    http://www.nhw.hume.org.au

    Tel: 03 5722 5486
    Mob: 0429 412 780

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