Setting

This audit is appropriate for all psychiatric services but may be more relevant to in-patient units.

Background

Incorporating evidence-based infection prevention and control advice into routine clinical care is believed to be important in reducing the incidence of preventable healthcare-associated infections.

Standards

There are numerous standards relating to infection control to which mental health trusts have an obligation to adhere (including National Institute for Health and Clinical Excellence, 2003; Infection Control Nurses Association, 2005; Department of Health, 2006).

Standards most relevant to the mental health trust can be selected for the audit process. Either single recommendations or combinations can be used. Four domains of care were selected for audit:

ᐅ Sharps. Sharps, needle-stick injuries, bites and splashes involving blood or other body fluids are managed in a way that reduces the risk of injury or infection (26 possible individual standards).

ᐅ Hand hygiene. Hands will be decontaminated correctly and in a timely manner using a cleansing agent, to reduce risk of cross-infection (25 possible individual standards).

ᐅ Personal protective equipment. Personal protective equipment is available and is used appropriately to reduce the risk of cross-infection (21 possible individual standards).

ᐅ Specimen handling. Specimens are handled in a way that negates the risk of cross-infection to all staff (18 possible individual standards).

The standards should be met in all areas in all domains.

Method

Data collection

The data related largely to the presence or absence of equipment on the ward. A tick-box data-collection sheet covering all relevant domains was used. This sheet contained the four main domain headings and the individual standards within each domain. For each standard the auditor indicated whether the standard was met (Yes / No / Not applicable).

Data analysis

Data were collated using spreadsheet software. Compliance with the standards was calculated for:

ᐅ the four domains described in the standards above

ᐅ the individual standards within each domain

ᐅ each trust, locality or team.

Resources required

People

This audit was coordinated by an audit facilitator; at each site at least one person collected data.

Time

Each individual required at least 1 hour to collect the data on the local ward or unit, but this depends on the size of the unit.