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Introduction
All healthcare staff are involved in audit and surveillance in some form, and it is an integral part of the Infection Prevention and Control Team’s work as they undertake activities in accordance with their annual audit and surveillance programme. This chapter explains what audit and surveillance are, their importance in the prevention and control of healthcare-associated infections and how they are undertaken, and gives examples of routine audit and surveillance activities.
Learning outcomes
After reading this chapter, the reader will:
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Be able to state the benefits of audit with regard to patient care and infection control practice.•
List the five main purposes of surveillance.•
Understand what is meant by alert organism, alert condition and notifiable diseases surveillance.•
List at least six alert organisms, six alert conditions and six notifiable diseases.•
List the organisms that form part of the national mandatory surveillance scheme.34
With regard to infection prevention and control, the majority of audits, which are designed to review certain aspects of patient care and compliance with clinical practice, involve the use of simple audit tools and, for the most part, can be undertaken by pretty much anyone at any time – as long as healthcare staff understand what it is they are being asked to audit, why and how to do it. This is important as the results are only as good as the information obtained and while this may be influenced by the design of the audit tool itself, it may also be down to the individual who is undertaking the audit and collating the information.
Box 3.1 lists examples of some infection control audits that staff may be required to undertake weekly or monthly.
Box 3.1 Examples of infection control audits that may be undertaken weekly or monthly
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Hand hygiene observational audits – compliance with the 5 Moments for Hand Hygiene approach and hand decontamination at the point of care (see Chapter 12)•
Observational audit of compliance with a Bare Below the Elbows policy (see Chapter 12)•
Commodes – cleanliness; decontaminated in between each episode of patient use and labelled•
Meticillin-resistant Staphylococcus aureus (MRSA) screening within 24 hours of admission to hospital (see Chapter 20)•
The number of patients on a ward on a given day of the week or month with a peripheral cannula or a urinary catheter in situ•
Completion of visual infusion phlebitis (VIP) scores (peripheral cannulae) (see Chapter 16)•
Base or static mattresses, zipped seat cushions and other items with a foam interior – integrity and cleanliness of inner and outer covers and foam core•
Antimicrobial prescribing – evidence of antimicrobial stewardship and compliance with antimicrobial prescribing guidelines (usually undertaken by an Antimicrobial Pharmacist or medical staff)•
Observational audits of compliance with standard precautions (personal protective equipment use and disposal; sharps handling and disposal; segregation of healthcare waste)•
Documentation – for example, completion of Infection Control Patient Management Plans or Pathways and completion of stool charts.More in-depth and complex audits, such as annual audits of Infection Control Environmental and Clinical Practice Standards, and audits of compliance with decontamination procedures in How many infection control-related audits take place within your clinical area? Who is respon- sible for undertaking the audits? How are the results fed back and acted upon?
Reflection point
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Endoscopy Departments, are generally undertaken by the Infection Prevention and Control Specialist Nurses in conjunction with Ward and Department Managers; antimicrobial prescribing audits may be undertaken by junior medical staff or the Antimicrobial Pharmacist. In some Infection Prevention and Control Teams (IP&CTs), the majority of audit and surveillance work may be undertaken by Audit and Surveillance Nurses. The Clinical Audit Department will also be involved, and may be asked by the IP&CT to undertake a Trust-wide audit across all clinical areas on a given day; for example, an audit of all patients with a vascular access device (VAD) in situ.
Box 3.2 lists examples of some of the larger infection control audits.
Box 3.2 Some examples of larger infection control audits that may be undertaken annually or more frequently
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Audit of hand hygiene facilities – for example, number and location of sinks; availability of liquid soap, paper towels and moisturiser; availability of alcohol hand rub; hand hygiene posters displayed; sinks compliant with the standards for clinical wash hand basins; and sinks and splash backs intact•
Hospital-wide audit of commodes (undertaken on a particular day) – for example, the number of commodes available in each ward or department; cleanliness or evidence of soiling; labelled with date and time cleaned; whether frame or parts are intact or require replacement•
Compliance with MRSA screening – for example, admission and long-stay screens, including whether staff are obtaining the correct clinical specimens as part of the screening process, and screening within the correct time frame•
Management of VADs – for example, number of patients on all wards with a VAD in situ, indication for and date of insertion, completion of all components of device insertion and ongoing care records•
Annual audit of compliance with Infection Control Environmental and Clinical Practice Standards•
Hospital-wide annual audit of compliance with the safe handling and disposal of sharps•
Annual audit of the management of healthcare staff presenting in Occupational Health or the Emergency Department following a needlestick injury•
Isolation rooms – for example, the number of rooms available on site; the number that are en-suite; whether the rooms are used appropriately; if in use – is appropriate signage displayed? Is the door closed? Are the room and equipment within it clean?•
Availability of Patient Information Leaflets – for example, are the ‘mandatory’ Infection Control Patient Information Leaflets displayed and available, and are they given to patients when required?•
Audit of compliance with endoscope decontamination standards – within Endoscopy Departments and other departments where a variety of scopes may be used and processed (i.e. Outpatients, Theatres, Intensive Care Unit and Day Surgery).36
Staff can feel overwhelmed with audit, as it can be applied to virtually any aspect of patient care, and subsequently it may actually be viewed by hard-pressed healthcare staff as a hindrance and an added burden in terms of paperwork. This may mean that it is poorly completed or not undertaken at all, and it may be viewed simply as another paper exercise, in which case it will lose its value.
Equally, if audit results are not acted upon (some actions may be beyond the scope of Ward and Department Managers or Matrons to implement, particularly if they require expenditure), or if staff do not receive feedback, then it is easy to become disillusioned and see no real value or purpose in the audit process.
The IP&CT have to engage with staff regarding infection prevention and control audits; they can be a powerful tool for change, and should be viewed positively, either as an indicator of the effectiveness of clinical practice, or as a benchmark to raise standards and improve patient care.
Poor audit findings indicate poor clinical practice and poor compliance with infection control poli- cies, and while this can be demoralising for staff, it indicates that there are risks for patients.
As mentioned in Chapter 4, the IP&CT will usually undertake some spot audits of compliance with clinical practice and compliance with infection control policies, for example:
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MRSA admission and long-stay screening, including clinical specimen collection•
The prescribing and administration of the MRSA decolonisation protocol•
Isolation or cohort nursing•
Commode cleanliness•
Use of, and cleanliness of, isolation side rooms•
VIP score recording.For audit to be effective, the results should be fed back to staff promptly; depending on the particular audit undertaken, immediate feedback is generally possible, followed by a written report. Audit results should also be fed back at staff meetings, form part of the agenda at clinical governance meetings, and be included in monthly and quarterly infection control reports to Divisions, Directorates and the Trust Board. Taking ownership of the results, good or bad, is all part of the process. This may mean developing an action plan, which may be undertaken by the IP&CT depending on the nature of the audit and then disseminated to the appropriate managers for implementation locally, or devised by Ward or Department Managers or Matrons, implemented and fed back to the IP&CT. The Action Plan itself will have to be audited to ensure effective implementation and sustained improvement.