Transcript Cold Chain Audit in Compliance to NSQHS Standard 4.10.3 [PDF

Cold Chain Audit in compliance to
NSQHS Std 4.10.3
Yang Liu
Stephen Lim
Pam Allsop
Pharmacy Department
Objective
 To assess compliance to the
Department of Health Vaccine Cold
Chain Guideline (OD0355/11)
 To promote medication safety at
AHS by ensuring correct storage of
temperature- sensitive products
Method
 Audited all refrigerators at AHS and the
corresponding community centres
 Compliance to the Department of Health
Vaccine Cold Chain Guideline
(OD0355/11) was assessed
 Survey period: 17th – 28th of June 2013
Std 4.10.3
 Temperature- sensitive medicines are
stored appropriately and in accordance
with manufacturer’s recommendation
 Use refrigerators specifically for cold chain
products only and ensure they are fitted
with temperature recording devices
What is Cold Chain?
 A system of transporting and storing
vaccines within the recommended safe
temperature range of +2ºC to +8ºC
Strive for 5!
Manufactured
Transported to
distribution centres
Shared responsibility
Administered
Cold Chain Breach (CCB)
 Occurs when the temperature falls outside
of the recommended temperature range of
+2°C to +8°C at any point during the cold
chain process
 Due to:
•
•
•
•
Refrigeration failure
Power outage
Overheating during transportation
Freezing
 Leading to a loss of efficacy to the vaccine
Vaccine storage management
 Delicate biological substances
 Ensure individuals receive an effective health
product
 Expensive and may be in short supply
 Destroyed or become less effective when
exposed to:
• Freezing (≤ 0°C)
• Heat
• Direct sunlight or fluorescent light
 Most vaccines can be regarded as damaged at
0ºC
Results
Finding
Type of fridge
Percentage compliance
Purpose built: 75%
Vaccine storage only
0%
Temperature monitored daily
57.9%
Temperature chart used for daily monitoring
68.4%
Person responsible for daily temperature
monitoring
Approved temperature recording device installed
Bar: 25%
Nurses: 80%
Other: 20%
84.2%
Fridge is plugged into essential power
84.2%
Signage affixed to the fridge door indicating its
contents
Fridge maintained according to manufacturer's
instructions
Fridge is centrally monitored
10.5%
Fridge cleaned routinely
31.6%
Aware of cold chain policy in this hospital
68.4%
63.2%
68.4%
Results
Discussion
 Vaccines and temperature- sensitive medicines
are stored in the same refrigerator throughout
the hospital
 Installing a purpose built refrigerator is not yet at
100% compliance on all wards
 Fridges must be consistently monitored daily
and temperatures recorded at the same time
each day
 No designated person is responsible for
educating or implementing policies
Discussion
 Refrigerators which contained vaccines did have
an essential power supply and monitored
centrally at AHS
 Updated imprest list of refrigerator contents were
placed on the door
 Do not store food and other goods in the fridge
 Equipment maintenance should be conducted
annually and include:
• Changing thermometer batteries
• Checking the accuracy of the thermometer
• Defrosting and cleaning the fridge
Discussion
 Wastage due to power failure
 Cost of new refrigerator ranges from
$1595 to $3195
Ward AMU
contents
worth
$323.69
Ward: ED
contents
worth
$5066.93
Conclusions
 The Department of Health Vaccine Cold
Chain Guideline (OD0355/11) was not
adhered to at AHS
 An individual needs to be appointed in
each area to oversee cold chain
management
 Ongoing education to all staff is vital
 Re- audits will be performed regularly to
ensure implementation of
recommendations
Thank you
Any questions?