IP&C Course Cathrina Ryan February 2016 Awaiting Names to April 2016 Standard 4 No Infection Have IP&C Link information sourced A/ODON be forwarded for Human Resource Prevention Control nurses working in via CNME Relevant CNM2 appropriate training Management Link Nurse in different departments Information cascaded Endoscopy in Nenagh Hospital to all departments Endoscopy Closed April 2016 Interest sought at Nurse completed ward level IP&C Study Day April 2016 Standard 6 Hand Hygiene Audit Have independent Hand Hygiene Audit Barbara Slevin November 2015 Completed Closed Hand Hygiene not carried out in audit carried out carried out by Barbara ADON IP&C Endoscopy Procedure Slevin ADON IP&C rooms in 2years UHL November 15 Score 100% – Standard 6 2 /10 Hand Hygiene Revisit 5 moments of Hand Hygiene 5 Celia Dwan CNM2 November 2015 Completed Ongoing Hand Hygiene opportunities not Hand Hygiene with moments refreshed & Ongoing 5 hand Hygiene staff with staff trainers now on the hospital site and 3 hand Hygiene auditors Standard 8 Improvement in Care bundles to be Ongoing Audits Relevant CNM2 May 2016 Await Guidance Ongoing Invasive Medical Documentation for incorporated to continued. Local and Barbara Slevin from Project Group Device related Peripheral Vascular NEWS Chart and HIQA Audit results ADON Lead infections are Care bundles & become part of fed back to staff. QIP Cathrina Ryan prevented or Urinary Catheter Care patients routine in place until A/ODON Monthly review via reduced bundles required observations documentation Metrics streamlined Standard 3 Blood Glucose Device All staff reminded for Hospital policy re Cathrina Ryan February 2016 Compliance appears Ongoing Monitoring Environment and and container being need to make up and circulated. CNMS A/ODON to be improved and Audit Facilities brought to patient’s clean down individual requested to monitor Relevant CNMS Reaudit September Management bedside tray when taking a and tutor staff in their 2016 with patients blood glucose work areas DiabeticCNS Outstanding Items From HIQA QIP 2014
Standard 4 Human Resource Management No Infection Prevention Control Link Nurse in Endoscopy Have IP&C Link nurses working in different departments in Nenagh Hospital IP&C Course information sourced via CNME Information cascaded to all departments Interest sought at ward level Cathrina Ryan A/ODON Relevant CNM2 February 2016 Awaiting Names to be forwarded for appropriate training Endoscopy Nurse completed IP&C Study Day April 2016 April 2016 Closed April 2016 Standard 6 Hand Hygiene Hand Hygiene Audit not carried out in Endoscopy Procedure rooms in 2years Have independent audit carried out Hand Hygiene Audit carried out by Barbara Slevin ADON IP&C UHL November 15 Score – 100% Barbara Slevin ADON IP&C November 2015 Completed Closed Standard 6 Hand Hygiene 2 /10 Hand Hygiene opportunities not Revisit 5 moments of Hand Hygiene with staff Hand Hygiene 5 moments refreshed with staff Celia Dwan CNM2 November 2015 & Ongoing Completed 5 hand Hygiene trainers now on the hospital site and 3 hand Hygiene auditors Ongoing Standard 8 Invasive Medical Device related infections are prevented or reduced Improvement in Documentation for Peripheral Vascular Care bundles & Urinary Catheter Care bundles required Care bundles to be incorporated to NEWS Chart and become part of patients routine observations Ongoing Audits continued. Local and HIQA Audit results fed back to staff. QIP in place until documentation streamlined Relevant CNM2 Barbara Slevin ADON Cathrina Ryan A/ODON May 2016 Await Guidance from Project Group Lead Monthly review via Metrics Ongoing Standard 3 Environment and Facilities Management Blood Glucose Device and container being brought to patient’s bedside All staff reminded for need to make up and clean down individual tray when taking a patients blood glucose Hospital policy re circulated. CNMS requested to monitor and tutor staff in their work areas Cathrina Ryan A/ODON Relevant CNMS February 2016 Compliance appears to be improved Reaudit September 2016 with DiabeticCNS Ongoing Monitoring and Audit Outstanding Items From HIQA QIP 2014
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