Public Board of Directors papers 27.01.22

There is regular monitoring and reporting of the testing turnaround times, with focus on the time taken from the patient to time result is available There is regular monitoring and reporting that identified cases have been tested and reported in line with the testing protocols (correctly recorded data)

Patient and staff test turnaround times are monitored by the staff testing team and reported at the trust wide sitrep / operational huddle (see Trust wide sitrep / operational huddle 11/01/22). As a green site, the trust results are prioritised when delays occur within our partner laboratory services. Compliance of Day 1, 3, 7 and every 7 days thereafter is monitored and reported at the trust wide sitrep / operational huddle (see Trust wide sitrep / operational huddle 11/01/22). To aid compliance and support the ward teams, a designated team of staff test ion the days required in line with trust and national guidance.

Testing omissions have occurred due to in patient pressures. Where this may have resulted in delays in asymptomatic detection and this be probable or definite hospital acquired an RCA is undertaken and reported through the IPC and trust governance structures. The trust is aware the policy for early detection and management of CPE has passed its review date.

These are picked up on subsequent days. A designated patient testing team now test patients easing the pressures on ward-based nursing teams. An initial review has been undertaken and the trust is assured that processes and practice remains safe and will undergo a full review and transcription to the new trust document format.

Screening for other potential infections takes place

Screening for other potential infections e.g. MRSA and CPE occurs on admission and is monitored by the IPC team. See Screening and Managements of MRSA Colonisation / Infection, Information for patients about MRSA screening, Policy for the early detection, management and control of Carbapenemase– producing Enterobacteriaceae (CPE), Information for patients about carbapenemase-producing enterobacteriaceae (CPE) screening and Carbapenemase-producing Enterobacteriaceae (CPE).

C1501: Infection prevention and control board assurance framework (24 December 2021 Version 1.8) – January 2022

130