MATTRESS AUDIT POLICY - ashfordstpeters.info
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MATTRESS AUDIT POLICY
Author: Sue Harris, Lead Nurse Tissue Viability
Status: Approval date: February 2019
Ratified by: Nursing, Midwifery and Allied Health
Professionals Professional Board
Review date: February 2022
Current version
Volume 6 First Ratified Next Review
is held on the Issue 5 Page 1 of 11
Medical Devices January 2004 February 2022
Intranet
History
Issue Date Issued Brief Summary of Change Approved by
1 Jan 2004 New policy
2 Jun 2010 Amended to incorporate MHRA Product and
alert MDA 2010/002. All Types of Medical
Bed Mattress Equipment
Group
3 Jun 2012 Updated to reflect current Trust Product and
mattress contracts Medical
Equipment
Group
4 Feb 2016 General review Product and
Medical
Equipment
Group
5 Feb 2019 Changes to static foam mattress Nursing,
checks Midwifery and
Allied Health
Professionals
Professional
Board
For more information on
the status of this Sue Harris, Lead Nurse Tissue Viability
document, please contact:
Policy Author Sue Harris, Lead Nurse Tissue Viability
Date of issue May 2019
Review due February 2022
Ratified by Nursing, Midwifery and Allied Health Professionals
Professional Board
Audience All staff
Current version
Volume 6 First Ratified Next Review
is held on the Issue 5 Page 2 of 11
Medical Devices January 2004 February 2022
Intranet
ASHFORD & ST PETER’S HOSPITALS NHS FOUNDATION TRUST
MATTRESS AUDIT POLICY
See also: Management, Use and Disposal of Medical Devices Policy
Cleaning & Disinfection Policy
Confidentiality Policy
1. INTRODUCTION
The Trust has a range of systems available to prevent and treat pressure ulcers. To
ensure the Trust makes the best use of the resources available, an audit of the static foam
pressure reducing mattresses when a patient is discharged and an annual audit of static
foam pressure reducing mattresses, supplied by Invacare is in place. The dynamic
pressure relieving mattresses are monitored via monthly usage reports from Talley.
2. DEFINITIONS
2.1 Dynamic Pressure Relieving System (DPRS)
The DPRS provides an alternating surface allowing tissues to experience periods of
no or very little pressure, thus facilitating capillary refill to prevent pressure induced-
damage to the tissues.
2.2 Static Foam Pressure Reducing Mattress (SFPRM)
The SFPRM closely follows the contours of parts of the body where there is direct
contact with the supporting surface and thereby redistributes pressure over a large
surface area.
3. PURPOSE OF AUDIT/USAGE REPORT
3.1 Dynamic Pressure Relieving System audit
• To monitor the contract with Talley
• To gather information on use of the dynamic systems within the Trust
3.2 Static Foam Pressure Reducing Mattress audit
• To ensure the mattress is ‘fit for purpose’ and clinically effective for the patient
• To ensure the condition of the cover and mattress insert is undamaged
• To ensure that if the cover and/or mattress insert is damaged and/or
contaminated that this is replaced
• To ensure that if the mattress has fluid ingression on the top cover, foam insert
and base foam, that the mattress is safely disposed of as clinical waste
4. FREQUENCY
4.1 Dynamic Pressure Relieving Systems
Monthly usage figures
4.2 Static Foam Pressure Reducing Mattress
• After each patient episode as part of the MHRA alert MDA 2010/002
• Annually as part of the contract with Invacare the mattress Manufacturers
5. DATA COLLECTED FOR DYNAMIC PRESSURE RELIEVING SYSTEMS AUDIT:
• Number of bed days used collated and supplied by Talley Group Ltd
6. DATA COLLECTED FOR MATTRESS AUDIT AFTER PATIENT EPISODE
Current version
Volume 6 First Ratified Next Review
is held on the Issue 5 Page 3 of 11
Medical Devices January 2004 February 2022
Intranet
• Ward Manager assurance form to be completed on Perfect Ward
• Clinical Nurse Leader to monitor this 6 monthly
7. DATA COLLECTED FOR ANNUAL STATIC FOAM PRESSURE REDUCING
MATTRESS AUDIT:
• Serial/batch number
• Mattress size and depth
• Condition of mattress i.e. outside coverings, foam inserts
8. PROCEDURE AND GUIDELINE FOR STATIC FOAM PRESSURE REDUCING
MATRESS AUDIT
8.1 After each patient episode in accordance with the Trust static foam mattress
flow chart and standard operating procedure (Appendix 1 and 2)
8.2 Annually over three days every June/July. All mattresses will be
checked and documented by the audit team from Invacare
9. RESPONSIBILITIES FOR DYNAMIC PRESSURE RELIEVING SYSTEM USAGE
9.1 Talley Group Ltd.
• To provide information on Dynamic Pressure Relieving Systems
• To monitor the number of rented systems on site
9.2 Equipment Library Representative
• To liaise with Talley to ensure mattress usage is recorded accurately
• To liaise with Talley to ensure adequate supply of dynamic pressure relieving
systems
• To liaise with clinical staff and Lead Nurse Tissue Viability to promote
appropriate use of dynamic pressure relieving systems
9.3 Ward Staff
• To ensure appropriate use of dynamic pressure relieving systems
• To remove, clean and return dynamic pressure Relieving Systems to the
Equipment Library
9.4 Tissue Viability Team
• To advise on the appropriate Static Foam Pressure Reducing Mattress or
Dynamic Pressure Relieving System for discharge
10. RESPONSIBILITIES FOR MATTRESS AUDIT ON PATIENT DISCHARGE
10.1 Clinical Nurse Leaders
• To oversee the audit in the clinical areas
10.2 Clinical Area Staff
• To perform the audit within their areas adhering to the Trust guidelines
10.3 Lead Nurse Tissue Viability
• To support the audit by ensuring that sufficient mattresses and components are
held in Trust stock
• To effectively manage the mattress budget
Current version
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Medical Devices January 2004 February 2022
Intranet
• To liaise with Invacare to ensure condemned blue mattresses are replaced
when under guarantee
11. DISSEMINATION AND IMPLEMENTATION
11.1 When the policy has been added to a meeting agenda for the purpose of
ratification, forward a draft copy to the Quality Department, who will arrange for it to
be made available on the Intranet.
11.2 All policies, when ratified, must be forwarded to the Head of Quality and Integrated
Governance, Quality Department, St. Peter’s Hospital.
11.3 The Head of Quality and Integrated Governance is responsible for ensuring that
policies are made available on the Trust Intranet, and ensuring all staff are made
aware of their existence.
11.4 Directors, Clinical Directors and Business Centre Managers are responsible for
ensuring that staff are made aware of policies, and receive specific training or
instruction if appropriate.
12. PROCESS FOR MONITORING COMPLIANCE WITH THE EFFECTIVENESS OF
POLICIES
12.1 All policies must include the process to be used to monitor its effectiveness.
Whichever method is chosen it must be explicit and documented e.g. audit, survey,
review, questionnaire etc.
12.2 This policy will be monitored as a whole through adherence to completion of the
Proforma for Ratification of Policies and Guidelines by ratifying committees.
13. EQUALITY IMPACT ASSESSMENT
13.1 The Trust has a statutory duty to carry out an Equality Impact Assessment (EIA)
and a copy is attached to this policy.
14. ARCHIVING ARRANGEMENTS
14.1 Responsibility for archiving trust-wide policies lies with the Quality Department
where all paper copies will be stored, and electronic folders have been set up to
hold master copies.
14.2 Requests for retrieval of documents can be made to the Quality Department.
14.3 Local policy (i.e. documents which are not Trust-wide and relate to specific areas)
are the responsibility of the originating department for archiving. The department
will need to have in place a process for the storage of documents which have
expired and an effective system for retrieval when necessary.
15.0 REFERENCES
• MHRA alert MDA 2010/002. All Types of Bed Mattresses
Current version
Volume 6 First Ratified Next Review
is held on the Issue 5 Page 5 of 11
Medical Devices January 2004 February 2022
IntranetEQUALITY IMPACT ASSESSMENT SUMMARY
NAME: SUE HARRIS
POLICY/SERVICE: MATRESS AUDIT POLICY
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.
Yes/No Comments
1. Does the policy/guidance affect one For each category describe
group less or more favourably than how you have involved
another on the basis of: stakeholders including
service users and
employees
Race and Ethnic origin (include gypsies No
and travellers) (consider communication,
access to information on services and
employment, and ease of access to
services and employment)
Disability (consider communication issues, No
access to employment and services,
whether individual care needs are being
met and whether the policy promotes the
involvement of disabled people)
Gender (consider care needs and No
employment issues, identify and remove or
justify terms which are gender specific)
Culture (consider dietary requirements and No
individual care needs)
Religion or belief (include dress, individual No
care needs and spiritual needs for
consideration)
Sexual orientation including lesbian, gay No
and bisexual people (consider whether the
policy/service promotes a culture of
openness and takes account of individual
needs
Age (consider any barriers to accessing No
services or employment, identify and
remove or justify terms which could be
ageist)
2. Is there any evidence that some groups No
are affected differently?
3. If you have identified potential No
Current version
Volume 6 First Ratified Next Review
is held on the Issue 5 Page 6 of 11
Medical Devices January 2004 February 2022
IntranetYes/No Comments
discrimination, for example, less than
equal access, are any exceptions valid,
legal and/or justifiable, for example a
genuine occupational qualification?
4. Is the impact of the policy/guidance No
likely to be negative?
5. If so can the impact be avoided? n/a
6. What alternatives are there to achieving n/a
the policy/guidance without the
impact?
7. Can we reduce the impact by taking n/a
different action?
If you have identified a potential discriminatory impact of this procedural document, please refer it
to the appropriate Action Group, together with any suggestions as to the action required to
avoid/reduce this impact.
Current version
Volume 6 First Ratified Next Review
is held on the Issue 5 Page 7 of 11
Medical Devices January 2004 February 2022
IntranetAppendix 1
Static foam mattress audit flowchart
All static foam mattresses are to be audited when a patient is discharged
Unzip mattress cover and inspect
inside of cover for any stains
No Stain Stain or rip, tear or hole
identified on inside of
mattress cover
Figures A, B
Re zip up mattress
Clean as per infection Check foam insert
control guidelines (pink and segmented)
Foam insert stained or damp or
malodourous or tears or segments
Yes missing or large amounts/ several
Check base foam (blue trough) points of staining on inside cover
—has stain gone all the way Figures C, D
through? Figure E
No
Yes No Collect correct colour
replacement
Condemn mattress mattress cover from local store
Breakdown into component
parts and dispose of in ward
clinical waste Remove stained foam insert,
roll up and place in clinical
waste
Order replacement mattress Order replacement foam insert from
from porters porters and replace by rolling into
base foam AND collect correct colour
replacement mattress cover from
local store
Replace cover and fully zip up
Ensure the correct colour cover is selected either
dark blue or light blue—the covers are NOT
interchangeable
Make up bed ready for next patient
Figure A Figure B Figure C Figure D Figure E
1Appendix 2
STANDARD OPERATING PROCEDURE
TITLE Audit and making good of static foam mattresses on patient discharge
PREPARED BY DATE January 2019
Sue Harris and Bibiana Baumgart
RATIFIED BY DATE
VERSION 0.1 REVIEW DATE
CONTENTS PAGE
Purpose 2
Scope 2
Competencies 2
Process/Procedure 2
Responsibilities 2
Audit 3
Risks 3
Mitigation for Risks 3
1PURPOSE
The purpose of this SOP is to describe the process of both auditing and making static foam
mattresses fit for purpose on patient discharge as appropriate
OBJECTIVE
To ensure the provision of quality care through the availability of static foam mattresses that
are fit for purpose through the audit and maintenance
To fully comply with MHRA 2010/002
SCOPE
This SOP applies to all static foam mattresses in the Trust
COMPETENCIES
Registered Nurses, Health Care Assistants, Nursing Apprentices, TCAPS and CAPS
To understand the process for auditing and maintaining the mattresses as below
PROCESS
This is detailed in Static foam mattress audit flowchart
Patient discharged from a static foam mattress
Mattress cover unzipped and visual check made of the inside of the mattress cover and
foam
No stains/holes/ rips or tears in mattress cover
No stains in foam insert
Mattress cover
Mattress cleaned as per infection control guidelines
Mattress cover showing a hole or staining larger than a 10 pence piece – new cover
obtained from local store and stained cover replaced.
Dispose of old cover in clinical waste
Foam insert stained – new insert requested from porters
Foam insert replaced and stained foam insert disposed of in clinical waste
NB if foam insert is stained both cover and inset must be changed even if there is no visible
stain or hole on cover
RESPONSIBILITIES
Health Care Assistants
• To complete this process when a patient is discharged
Registered Nurse
• To ensure this process is completed when a patient is discharged
Nurse in charge
• To ensure all staff are aware of the need to check mattress’ on patient discharge
Ward Manager
• To ensure all staff are aware of the need to check mattress’ on patient discharge
• To complete monthly self-assurance on Perfect Ward
Clinical Nurse Leader
• To audit the self-assurance on Perfect Ward 6 monthly
Tissue Viability Nurse
• To ensure there are sufficient stocks ordered to facilitate this process
Porters
• To deliver mattress parts to the wards/ areas as requested
Ward PA
• To ensure sufficient mattress covers are held as stock within the ward/department
by ordering additional covers as required from the portering department
2AUDIT
Ward Manager
• To complete monthly self-assurance on Perfect Ward
Clinical Nurse Leader
To audit the self-assurance on Perfect Ward 6 monthly
RISKS
Trust staff not aware of the Trust policy for the management of static foam mattresses
That mattresses are not fit for purpose
MITIGATION FOR RISKS
Ward Managers to ensure that all staff are aware of this
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