PROGRESS has been made in improving infection control in Raigmore Hospital’s theatre department – but health inspectors have found "dissapointing" evidence of poor hand hygiene and say more improvements are needed.
A team from the Healthcare Environment Inspectorate (HEI) made an unannounced visit to the 11-theatre department to check whether it had complied with four requirements set during an earlier inspection last May.
They included improvements to the management and decontamination of surgical equipment and the management of bed linen.
During the two-day follow-up visit, the inspectors found all the requirements had been met but identified two further issues relating to infection control data compliance which required action.
The HEI also noted that on day one of the visit compliance with hand hygiene was poor when cleaning the theatres between patients – staff were seen putting on and removing personal protective equipment, such as gloves, without "decontaminating" their hands – a term which generally refers to the use of hand gel or handwashing.
But on day two this had improved.
It recommended NHS Highland should consider the location of alcohol-based hand rub in the theatres and disposal rooms to ensure it was available where it was most required.
Catherine Stokoe, the hospital’s infection control manager, welcomed the report.
She said the inspection team saw the overall standard of environmental cleanliness throughout the main theatre department and outlying theatres was good.
"Feedback from the inspection team was positive and all previous requirements have been met," she said.
"However, we are disappointed that a further two requirements have been identified.
"Work has already progressed on these to ensure we scrutinise our standard infection control precautions audit process and that a rolling hand hygiene programme is in place."
During February’s follow-up visit, the inspectors reviewed the results of 16 hand hygiene audits in the main theatre department carried out by theatre staff from July to December 2016. The results ranged from 45 per cent to 100 per cent compliance while the average score was 75 per cent.
The HEI said the way the results were combined before presentation to NHS Highland committees meant good audit results in one clinical area may hide poor results in another area.
"We spoke with senior managers and the senior infection prevention and control nurse about the hand hygiene compliance audit results in the theatre department," the HEI report stated.
"We were told that staff were reminded verbally of any required actions following these audits. However, no action plans were written to address these non-compliances."
Senior managers agreed that action should have been taken to address the poor audit results.