Mr. Curt Werner1
1Gold Coast Private Hospital, Southport, Australia
Biography:
Curt has worked in Infection Control for 15 years and holds a Master’s degree in the field. He has published two research papers on MRSA clearance. In his previous role, he served as both Infection Control Manager, overseeing six facilities, and National Staff Health Manager. Currently, Curt is the Infection Control Coordinator at Healthscope. Within 12 months of joining Gold Coast Private, he was honoured with the individual ACE award. Curt's extensive experience and dedication to infection control underscore his commitment to enhancing healthcare quality and safety.
Abstract:
Background
This study addresses two primary opportunities: whether our facility quality assurance is meeting AS5369 standards within both Central Sterile Services Department (CSSD) and Endoscopy departments and aligning our Legionella micro-testing with the Water Risk Management Plan.
Actions
A comprehensive gap analysis revealed several issues: absence of tracking and tracing for scopes' micro-testing, lack of records for scopes or washer disinfectors, and missing visibility for micro-testing results as mandated by AS5369. Additionally, there was no visibility on actions taken to remediate out of range sample results.
Results
To address these gaps, we partnered with a consultant, developing a robust plan of all water management including utilising a compliance software dashboard to allow open disclosure of test results, management of actions and reporting by exception. The software also allowed us to develop a facility-wide flushing program adaptable to operational needs (such as ward closures) through a mobile app, ensuring specific asset locations and ease of use for staff. Automated quarterly reporting for Queensland Health's Legionella Program was introduced, abolishing paper-based reports and spreadsheet record keeping.
Conclusion
Implemented measures have enhanced transparency among key stakeholders regarding water sample results and assigned accountability to department managers, ensuring all records and correspondence is tracked. Testing and results are now aligned with AS5369. A clear chain of command has been established, and protocols for addressing out-of-range results have been documented including corrective actions. This has allowed our facility to demonstrate compliance during accreditation with sample schedules, result trend analysis and corrective actions in one system.