Oppsummeringsrapport etter tilsyn med smitteisolering ved 10 helseforetak i 2006

NORSK SAMMENDRAG: Helsetilsynet og Arbeidstilsynet gjennomførte høsten 2006 tilsyn med kontaktsmitte- og luftsmitteisoleringen ved ti helseforetak. Dette ble gjort som ledd i videreføringen av kampanjen ”God Vakt” og som oppfølging av ”Handlingsplan for å forebygge sykehusinfeksjoner 2004 – 2006.”\ud \ud Ved tilsynet avdekket Helsetilsynet at organiseringen av smittevernpersonellet ved flere helseforetak ikke var i samsvar med myndighetskravene. Personellressursene avsatt til smittevernarbeid var heller ikke tilstrekkelig over alt. I halvparten av helseforetakene var antallet og fordelingen av isolat betydelig lavere enn ønskelig. I tillegg var ikke alle isolatene i samsvar med Isoleringsveilederens anbefalinger. Ikke alle helseforetakene sikret at arbeidstakerne gjennomgikk nødvendige undersøkelser for MRSA og tuberkulose. Det var mangler ved vedlikehold, oppdatering og etterlevelse av infeksjonskontrollprogrammet ved noen helseforetak.\ud \ud Arbeidstilsynet konkluderte med at smittevernarbeidet ikke var tilstrekkelig prioritert i de fleste av helseforetakene. Det var laget systemer for smittevernet ut fra smittevernloven, mens arbeidsmiljølovens forskrifter syntes mindre kjent. Avvikssystemene fungerte heller ikke optimalt flere steder. Toppledelsens oppbakking og kontroll av smittevernarbeidet virket ofte mangelfull. Ved flere av helseforetakene påpekte Arbeidstilsynet at det var utilstrekkelig med smittevernpersonell. Systematiske risiko- og sårbarhetsanalyser manglet de fleste steder. Rutiner for vaksinering sikret ikke at alle med behov fikk tilbud. Smittevernopplæringen gikk stort sett inn i annen opplæring. De fleste steder fikk ikke de ansatte smittevernundervisning før de ble satt i arbeid med smitterisiko. Elektroniske infeksjonskontrollprogram ble av mange oppfattet som vanskelig tilgjengelig. Ved ett helseforetak hadde ikke verneombudet praktisk mulighet til å ivareta sine lovpålagte oppgaver. Et annet helseforetak hadde ikke oppdaterte prosedyrer for HMS.SUMMARY IN ENGLISH: The Norwegian Board of Health Supervision and the Norwegian Labour Inspection Authority\ud \ud In the autumn of 2006, the Norwegian Board of Health Supervision and the Norwegian Labour Inspection Authority carried out supervision of isolation of contact infection and air-borne infection at ten health trusts. This was carried out as part of the Labour Inspection Authority’s campaign Be on your Guard (God Vakt) and as a follow-up of the Norwegian Government’s Plan of Action for the Prevention of Hospital Infections 2004-2006. \ud \ud Supervision showed that organization of personnel responsible for control of infection at several of the health trusts was not in accordance with the requirements laid down by the authorities. Also, personnel resources allocated to control of infection were not always sufficient. In half of the health trusts, the number of isolation units was considerably lower than was desirable. In addition, not all isolation units were run in accordance with the recommendation in the Guidelines for Isolation Units. Not all the health trusts ensured that all staff had been tested for MRSA (Methicillin-resistant Staphylococcus aureus) and tuberculosis. Some of the health trusts did not adequately ensure that the infection control programme was followed, maintained and updated.\ud \ud The Norwegian Labour Inspection Authority concluded that work with control of infection was not given adequate priority by most of the health trusts. Systems for control of infection were developed according to the Communicable Diseases Control Act, but the regulations in the Working Environment Act seemed to be less well known. Also, the systems for dealing with nonconformities were inadequate in many places. Not all the top leaders supported and controlled work with control of infection adequately. At several of the health trusts, the Norwegian Labour Inspection Authority pointed out that it is not sufficient just to have personnel with responsibility for control of infection. Systematic risk and vulnerability analyses were not carried out in most places. Routines for vaccination did not ensure that everyone who needed to be vaccinated were offered this. Training in control of infection was largely incorporated in training in other areas. In most places, the staff had not been given training in control of infection before they began to work in situations where there was a risk of infection. Many of the staff regarded access to electronic infection control programmes as difficult. In one health trust, the health and safety officer did not have the possibility to carry out his duties in accordance with statutory requirements. In another health trust, there were no updated procedures for work with health and safety