An audit of radiology department readiness in the event of an infectious outbreak

To provide a framework to assess the readiness of a radiology department to cope with an infectious outbreak by comparing measurable markers of preparedness against advice and guidelines from the UK Department of Health and the Health and Safety Executive.

This audit does not intend to focus on any one single disease, but seeks to help improve the preparedness of a radiology department to maintain essential services in the event of an infectious outbreak and reduce the risk of transmission between patients and staff of such a disease.

The standard: 

• A written plan should be established detailing how the department would function where a significant outbreak was to occur. Such a plan should co-ordinate with any hospital wide plan and should have input from the infection control team

• Staff should be made aware of the plan in advance with dedicated time made available for explanation

• Named individuals should be responsible for acting as ‘leads’ in updating and executing the department plan

• A record of regular hand hygiene training should be kept

• Training should be provided to ensure that protective equipment is used appropriately

• Provision should be made where possible to divide all staff, equipment and areas into ‘clean’ and ‘dirty’ reducing transmission risk

• A written protocol should be established following consultation with the infection control team with regard to cleaning radiology equipment

• A database of competencies should be established to help in anticipation of staff role reassignment

Target: 

Records and evidence of the above standards should be demonstrated with 100% compliance.

Indicators: 

Each component of the audit questionnaire should be completed and signed off when the appropriate evidence is demonstrated.

Data items to be collected: 

• The departmental written plan; ensure there is no contradiction with the hospital wide infectious outbreak plan

• Record of attendance at departmental infectious outbreak readiness briefings where the written plan is explained

• Evidence of named leads in department for implementing and updating the departmental written plan

• Hand hygiene training records for all staff

• Record of staff training for use of personal protective equipment

• Evidence of written plan to divide staff and resources into ‘clean’ and ‘dirty’ groups

• The written protocols developed with infection control for cleaning department equipment

• A recently updated department skills database

Suggested number: 

Where records of attendance and training are required it is suggested that evidence of 100% attendance and training of radiology department staff is sought.

The main issues are likely to be centred around incorporating the departmental infectious outbreak plan with any wider hospital plan and it is recommended that the hospital infection control team is consulted in the development of a departmental written plan.

• Time for data collection

• Infection control team

• Audit facilitator

• Report writing

1. Pandemic flu – workplace guidance 2008. Health & Safety Executive. http://www.hse.gov.uk/biosafety/diseases/pandflu.htm 

2. Government guidance on Pandemic flu. Updated guidance 2017. https://www.gov.uk/guidance/pandemic-flu#history

3. Centres for Disease Control and Prevention (CDC) Preparation and Planning .  Bioterrorism readiness plan: a template for healthcare.  https://emergency.cdc.gov/planning

Dr. Shouvik Saha & Dr. David Howlett, updated by A Marzoug