Infection Control AuditInfection Control Auditin Physiotherapyin Physiotherapy

Ms Lydia Wong (PTII, RHTSK)Ms Lydia Wong (PTII, RHTSK)

Mr. Eric Wong (SPT, UCH)Mr. Eric Wong (SPT, UCH)

ObjectivesObjectives1.1. To introduce IC audit / inspection requirements To introduce IC audit / inspection requirements

for PTfor PT

2.2. To develop a comprehensive inspection To develop a comprehensive inspection checklist checklist on ICon IC for PTfor PT

3.3. To uphold the To uphold the IC standardsIC standards in PT practicesin PT practices

4.4. To ensure PT workplaces are To ensure PT workplaces are compiling to the IC compiling to the IC requirementsrequirements set by LD set by LD

ContentContent

Conclusion and Q&A (5)Conclusion and Q&A (5)

2. Development of a 2. Development of a comprehensive comprehensive checklist for IC checklist for IC audit / inspection audit / inspection Group discussion (15)Group discussion (15)Presentation (30)Presentation (30)

1. Sharing on IC 1. Sharing on IC requirements (10)requirements (10)

ContentContentDevelopment of a comprehensive checklist Development of a comprehensive checklist for IC audit / inspectionfor IC audit / inspection

Identify audit areaIdentify audit area

Explore componentsExplore componentsCompileCompilerecommendationsrecommendations

Sharing on IC RequirementsSharing on IC Requirements

1.1. Local OrganizationLocal OrganizationHospital - Senior Management, ICTHAHO - ICT, CHPGovernment - DH, LD

2.2. Oversea Accreditation BodyOversea Accreditation BodyJoint Commission International (JCI)

Sharing on IC RequirementsSharing on IC Requirements

Medical Committee

Develop clinical protocol for care of patients who require ICU care but still remain in general wards

Care of Patient

Maintenance Clarify preventive maintenance protocol of minor equipment

Equipment

ICT Clarify transfer trolley cleaning procedure after each use

Infection

Infection Team Compare collected data among different hospitals for benchmarking

Infection

ResusCommittee

Clarify checking protocols of contents in resuscitation trolley

Resuscitation

Nursing Use uniform pain scale for all patientCommunication

All Staff Wear staff ID card in hospital areaStaff ID

Nursing Document time of nursing assessmentDocumentation

All doctors Use doctor code for easier identification of doctor

Documentation

All units concerned

Write down the date of opening the drug vial and observe the valid duration for use after the drug vial is opened

Medication

Pharmacy Replace expired fire extinguisherFire

All wards Screen off extra beds in corridor to allow for more privacy

Privacy

AED Keep screen closed at patient cubical when patent is in the area

Privacy

Follow upOpportunity – ActionRisk Category

Sharing on IC RequirementsSharing on IC Requirements

1.1. To ensure the To ensure the safetysafety of patients and of patients and HCWHCW

2.2. To ensure the To ensure the quality of patient carequality of patient care

3.3. To To minimizeminimize cross infectioncross infection

Identification of Audit /Identification of Audit /Inspection AreasInspection Areas

1.1. Physiotherapy DepartmentPhysiotherapy DepartmentEnvironmentPolicy & System

2.2. Physiotherapy Practices Physiotherapy Practices - All Settings3.3. Staff Competency & KnowledgeStaff Competency & Knowledge

Physiotherapy DepartmentPhysiotherapy Department

9. SESAS

10. Availability of IC link person

8. Contingency plan for AI / SARS

7. HA / Hospital infection control plan for AI7. Signage and posters

6. Accessibility of infection control policy manual6. Availability of sharp box

5. Infection control training records5. Availability of PPE

4. Sharp injury records4. No potted plants in patient area

3. N95 fit test records3. Handling of soiled linen & staff uniform

2. Audit / Inspection records2. Waste disposal

1. Vaccination records1. Cleansing & disinfection

Policy & SystemEnvironment

Physiotherapy PracticesPhysiotherapy Practices

5. Triage of patients with isolation precautions

6. Cohort of isolated patients for treatment

4. Cleansing & disinfection of equipment

3. Hand hygiene

2.5 Protective Precaution

2.4 Respiratory Precaution

2.3 Droplet Precaution

2.2 Contact Precaution

2.1 Standard Precaution2. Standard +/- transmission base precautions

1. FTOCC checking

In / OutIn / Out--patient & community servicespatient & community services

Staff CompetencyStaff Competency

6. Know how to handle spillage / splashing of secretions/ body fluids

5. N95 fit check

4.1 Washing & hand rub4. Hand hygiene technique

3. Application, removal and disposal of PPE

2. Understand various kinds of precautions

1. Regular update on infection control issues

Audit / Inspection MeansAudit / Inspection Means

Documentation reviewDocumentation review

Ask staff

Ask patientAsk patient

Observations