CONTROLLED DOCUMENT

Infection Prevention and Control Policy

CATEGORY:

Policy

CLASSIFICATION:

Clinical/Governance

PURPOSE:

To set out the principles and framework for the management of Infection Prevention and Control within the Trust, to ensure that all staff understand their roles and responsibilities.

Controlled Document Number:

67

Version Number:

6

Controlled Document Sponsor:

Executive Chief Nurse/Director of Infection Prevention and Control

Controlled Document Lead:

Lead Nurse Infection Prevention and Control

Approved By:

Board of Directors

On

23 July 2015

Review Date

July 2018

Distribution: •

Essential Reading for:

•

Information for:

Infection Prevention and Control Policy Document Control No: 67

All Trust Staff

Issued: July 2015 Version: 6

1

Contents Paragraph

Page

1

Policy Statement

3

2

Scope

3

3

Framework

3

4

Duties

6

5

Implementation

10

6

Monitoring

10

7

References

10

8

Associated Policy and Procedural Documentation

11

Infection Prevention and Control Policy Document Control No: 67

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1. Policy Statement 1.1 The Trust is accountable for the provision and range of Infection Prevention and Control services it provides. This includes the provision of an Infection Prevention and Control Policy and associated procedural documents, staff training and surveillance programmes. Within the Trust, all staff have a responsibility for infection prevention and control. Specialist advice and support is also provided via the Infection Prevention and Control Team (IPCT) and Consultant Microbiologists. 1.2 The aim of the Infection Prevention and Control Policy is to ensure that the Trust provides an environment and system of care which minimises the risk of infection to patients, staff and visitors. 1.3 The key objectives of this policy are: 1.3.1. To set out the principles and framework for the prevention and control of infection within the Trust; 1.3.2. To ensure that all staff understand their roles and responsibilities in connection with the prevention and control of infection within the Trust; 1.3.3. To ensure that all staff understand the importance of correct medical device decontamination and processes in connection with the prevention and control of infection within the Trust; and 1.3.4. To ensure compliance with national policy and guidance related to infection prevention and control. 2. Scope The policy applies to all individuals employed by the Trust including staff in all wholly owned clinical subsidiaries, Cofely and sub-contractors, students, locum and agency staff and staff employed on honorary contracts who are involved in Trust business on or off Trust premises. The policy also applies to Cofely staff and contractors. In addition, where appropriate, it applies to patients and visitors. 3. Framework 3.1 The Trust shall implement procedures for the prevention and control of infection, which will include those items described in section 8 (below). Compliance with all such procedures is mandatory. Failure by any member of staff to comply with this policy or any of its associated procedures may result in disciplinary action.

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3.2 This policy and all associated procedural documents, audit tools and information will be continually reviewed and updated to reflect evolving clinical practice, up to date legislation and guidance relevant to infection control and decontamination. The Document Sponsor shall approve all procedural documents associated with this policy, and any amendments to such documents, and is responsible for ensuring that such documents are compliant with this policy 3.3 Prevention The Infection Prevention and Control Team will: 3.3.1 Provide surveillance and rapid feedback of infection rates, antibiotic resistant bacteria and alert organisms to clinical areas; 3.3.2 Ensure the provision of timely information, advice and support to all Trust employees, patients and visitors on matters relating to Infection Prevention and Control; 3.3.3 Support local investigation and management of incidents relating to infectious diseases and alert organisms to enable clinical teams to prevent further incidence through learning and service improvement; 3.3.4 Provide advice regarding infection prevention and control aspects of new builds/refurbishments. 3.4

Control 3.4.1 When an incident occurs, or when patients are potentially, or identified as being, infected/colonised with an infectious agent or with an infectious disease, the patient’s care will be managed in accordance with the Trust’s relevant infection prevention and control procedures. 3.4.2 Staff with infections or who are at risk of infection through exposure or inoculation injury, will be managed in accordance with occupational health and safety procedures related to the prevention of transmission of infection.

3.5

The Trust will use key performance indicators to demonstrate the performance and effectiveness of infection control and the risk management process within each ward or department.

3.6 Trust Infection Prevention and Control Group (IPCG) The Trust Infection Prevention and Control Group (IPCG) is directly accountable to the Chief Executive and Board of Directors (via the Chief Nurse/Director of Infection Prevention and Control). IPCG Infection Prevention and Control Policy Document Control No: 67

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advises on Infection Prevention and Control policies, procedures and guidance, provides advice and support on the implementation of policies and monitors the progress of the Infection Prevention and Control annual plan. 3.7 Infection Prevention and Control Team (IPCT) 3.7.1 The Infection Prevention and Control Team (IPCT) consists of: 3.7.1.1 Lead Doctor Infection Prevention and Control 3.7.1.2 Lead Nurse Infection Prevention and Control 3.7.1.3 Clinical Nurse Specialists - Infection Prevention and Control 3.7.1.4 Antimicrobial Pharmacist 3.7.1.5 Infection Prevention and Control Clinical Scientist 3.7.1.6 Administrative staff 3.7.2 The IPCT can also seek additional specialist advice from: 3.7.2.1 Consultant Microbiologists 3.7.2.2 Consultant Virologist 3.7.2.3 Decontamination Advisor 3.7.2.4 Decontamination and Sterile Services Manager 3.7.3 The key role of the IPCT is to: 3.7.3.1 Provide specialist advice and support to clinical teams and staff, including surveillance and identification and control of outbreaks 3.7.3.2 Provide education for staff in relation to Infection Prevention and Control procedures, including hand hygiene 3.7.3.3 Produce and progress the Infection Prevention and Control annual plan which will be agreed by the Infection Prevention and Control Group (IPCG) and the Board of Directors. Quarterly updates on progress will be reported via IPCG 3.7.3.4 Provide reports to the IPCG and Board of Directors relating to alert organisms, outbreaks and issues related to infection prevention and control 3.7.3.5 Produce and/or update Infection Prevention and Control policy and associated procedures. 3.8 Being Open 3.8.1 The organisation supports the principles of being open. Where an infection occurs, patients and their carers will be given information about infection prevention and control, including leaflets. Discussions with patients and/or their carers must be documented in the patient’s notes.

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4. Duties

4.1 Board of Directors 4.1.1 The Board of Directors will ensure that effective systems are in place for Infection Prevention and Control and will: 4.1.2.1 Ensure that there is a Board level lead for Infection Prevention and Control – the Director of Infection Prevention and Control (DIPC) in this Trust is the Chief Nurse;

4.2

4.1.2.2

Ensure that an Infection Prevention and Control Group (IPCG) is in place;

4.1.2.3

Approve the Infection Prevention and Control annual plan; and

4.1.2.4

Receive reports relating to Infection Prevention and Control performance.

Chief Executive The Chief Executive (CEO) is ultimately responsible for ensuring that there are effective arrangements in place for Infection Prevention and Control and that appropriate resources are made available to manage the risks of infection. The CEO will ensure the prevention and control of healthcare associated infection as a core part of the organisation’s clinical governance arrangements.

4.3

Director of Infection Prevention and Control (DIPC) 4.3.1 The Director of Infection Prevention and Control (DIPC) will oversee local control of Infection Prevention and Control procedural documents and their implementation and be responsible to the Board of Directors for the Infection Prevention and Control within the Trust. The post holder will report directly to the Chief Executive and the Board of Directors. 4.3.2 The DIPC will assess the impact of all existing and new Infection Prevention and Control procedural documents and plans on infection and make recommendations for change. 4.3.3 The DIPC shall approve all procedural documents associated with this policy and any amendments to such documents, and is responsible for ensuring that such documents are compliant with

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this policy. This is to include the Annual Plan and development of assessment of risk. 4.4 Lead Doctor Infection Prevention and Control 4.4.1 The Lead Doctor Infection Prevention and Control is the medical lead for the Infection Prevention and Control Team. The Lead Doctor reports managerially to the Chief Nurse/Director for Infection Prevention and Control via the Director of Estates and Facilities and is professionally accountable to the Medical Director. 4.4.2 The Lead Doctor Infection Prevention and Control supports the Director for Infection Prevention and Control in developing the Infection Prevention and Control policy, provides clinical expertise in ensuring that the policy and associated procedural documents are appropriate and applicable. 4.4.3 The Lead Doctor Infection Prevention and Control also supports the development of monthly, quarterly and annual reports as required for the Board of Directors. 4.5 Lead Nurse Infection Prevention and Control 4.5.1 The Lead Nurse Infection Prevention and Control line manages the Infection Prevention Control Team clinical nurse specialists, the clinical scientist, the antimicrobial pharmacist and the administrative staff. The Lead Nurse works in partnership with the Lead Doctor Infection Prevention and Control on all aspects of infection prevention and control. 4.5.2 The Lead Nurse Infection Prevention and Control also has a specific role in nursing leadership, service improvement and oversees the implementation of the Trust Infection Prevention and Control annual plan. The Lead Nurse provides the clinical nursing expertise to the team to ensure that the policy and associated procedural documents are appropriate and applicable. 4.5.3 The Lead Nurse Infection Prevention and Control also supports the development of monthly, quarterly and annual reports as required for the Board of Directors. 4.6 Director of Estates and Facilities 4.6.1 The Director of Estates and Facilities line manages the Lead Doctor Infection Prevention and Control and Lead Nurse Infection Prevention and Control and works in partnership with the Lead Doctor, Lead Nurse and DIPC on all aspects of infection prevention and control, including effective cleaning. Infection Prevention and Control Policy Document Control No: 67

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4.7

Decontamination Advisor and Decontamination Sterile Services Manager 4.7.1 The Decontamination Advisor and Decontamination Sterile Services Manager support the Infection Prevention and Control Team and Clinical Teams by providing expert advice and guidance on all decontamination issues concerning medical device decontamination and decontamination processes throughout the Trust ensuring that national guidance and recommendations for decontamination are implemented. 4.7.2 The Decontamination Advisor and Decontamination Sterile Services Manager oversees the external contract to support IPC. 4.8 Clinical Nurse Specialists - Infection Prevention and Control 4.8.1 The Clinical Nurse Specialists - Infection Prevention and Control provide leadership and specialist advice on Infection Prevention and Control to patients, carers and all disciplines and grades of staff, in accordance with the Infection Prevention and Control policy and procedures. They undertake environmental audits, surveillance and teaching as outlined in the Infection Prevention and Control programme. 4.9 Infection Prevention and Control Link Staff 4.9.1 Act under the supervision of the Clinical Nurse Specialists Infection Prevention and Control, as a resource and role model for Divisional colleagues. They provide information to assist in the early detection of outbreaks of infection to the Clinical Nurse Specialists - Infection Prevention and Control. 4.10 Divisional Directors, Divisional Directors of Operations, Associate Directors of Nursing, Clinical Service Leads, Group Managers and Matrons 4.10.1 Are accountable for implementing and monitoring any identified Infection Prevention and Control measures within their designated areas and scope of responsibility. 4.10.2 In situations where significant risks have been identified and where local control measures are considered to be potentially inadequate, managers are responsible for bringing these risks to the attention of the Chief Nurse/Director of Infection Prevention and Control if local resolution has not been satisfactory achieved.

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4.10.3 Individual Divisional management teams are responsible for ensuring that clinical staff attend Infection Prevention and Control mandatory training and adhere to the Trust Infection Prevention and Control policy and associated procedures. They are also responsible for identifying individual staff members to act as a local resource for infection control within the Division. 4.11 Directors/Managers of Other Staff Groups 4.11.1 Are accountable for implementing and monitoring any identified Infection Prevention and Control measures within their designated areas and scope of responsibility. 4.11.2 In situations where significant risks have been identified and where local control measures are considered to be potentially inadequate, managers are responsible for bringing these risks to the attention of the Infection Prevention and Control Team / Infection Prevention and Control Group if local resolution has not been satisfactory achieved. 4.11.3 Individual management teams are responsible for ensuring that staff adhere to the Trust Infection Prevention and Control policy and associated procedures. Managers should ensure that appropriate information and training is provided to staff without access to the intranet. 4.12 All Employees 4.12.1 Employees are required to have up to date knowledge of principles and practices of Infection Prevention and Control and decontamination for their area of work and must undertake annual mandatory Infection Prevention and Control training. The Infection Prevention and Control and Decontamination guidelines are available on the Trust website. The Trust promotes a culture where all members of the healthcare team share the responsibility for infection prevention and control. They must comply with the Trust Infection Prevention and Control policy and associated procedures.

5. Implementation 5.1 Appropriate training for all staff, including those employed by support services and those with temporary or honorary contracts, will be provided annually and defined elements of this shall be mandatory in accordance with the Policy on Mandatory Training. Mandatory training will be delivered via a range of approaches including face to face, e-learning and for non-patient facing staff leaflet.

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6. Monitoring 6.1

The progress of Infection Prevention and Control is monitored through the Infection Prevention and Control Group (IPCG) which is chaired by the Chief Nurse/Director for Infection Prevention and Control and is accountable to the Chief Executive and the Board of Directors.

6.2

The IPCG membership will include Divisional representatives who will provide progress against a range of Infection Prevention and Control performance indicators, including hand hygiene and uptake of mandatory training.

6.3

The IPCG meets monthly (10 meetings per year). Minutes of the IPCG are circulated and outputs are reported to the Board of Directors and the Clinical Quality Committee via the Care Quality report.

6.4

A programme of audits agreed by the Chief Nurse/Director for Infection Prevention and Control will be carried out to establish the effectiveness, implementation of, and the extent of compliance with this policy and its associated procedures to provide independent assurance that an appropriate and effective system of managing infection control is in place. This includes the clinical dashboards and the process of route cause analysis.

6.5 7. References 7.1 Department (2008)

of

7.2 Department (2006)

of

7.3 Department (2005)

of

Health Going Further Faster II: applying the learning to reduce HCAI and improve cleanliness Health The Health Act 2006 (revised 11th January 2008) Code of Practice for the Prevention and Control of health care associated infections Health Saving Lives: delivery programme (revised 2007 & 2010) To reduce health care associated infections

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8. Associated Policy and Procedural Documentation The Infection Prevention and Control policy should be used in conjunction with the following policy and procedural documents: UHB Policy or Procedure Use of protective equipment (PPE)

Control Number 417

Version 2

Hand hygiene

388

4

Assistance dogs

687

2

Use of fans

507

4

Safe handling of linen

414

3

Skin antisepsis prior to invasive procedures

576

1

Outbreaks of diarrhoea and vomiting

392

5

Legionella control

518

1

Hospital acquired legionnaires disease

399

1

Outbreaks of infectious diseases

390

2

CG109

3

Sharps safety

637

2

Staff Health Procedures Communicable Infections

782

3

Cleaning and sterilization of patient implant and screws during maxillofacial reconstruction surgery Decontamination of reusable medical devices

511

3

161

6

Deep cleaning

386

2

Storage, use and management of endoscopes through the 31 day endoscope drying cabinets Management and operation of endoscope washer-disinfectors

510

3

406

2

Decontamination of flexible endoscopes

171

3

Spillage management (excluding chemicals and radioactive)

387

5

Cleaning and disinfection of shared patient equipment

405

2

Single-use medical devices

174

2

CG060

4

Antimicrobial prescribing code

719

2

Notification of infectious disease

403

3

Clostridium difficile

819

2

Diptheria

682

2

Multi resistant Gram negative bacilli

409

2

Influenza

649

2

CG108

2

Control of VZV

394

1

Management of suspected VHF

395

3

Scabies

686

2

Blood borne viruses

398

3

Management of TSE

391

2

Waste

152

3

Isolation

Antimicrobial prescribing

Patients with TB

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PUB_002

5

Death of a patient with an infectious condition

418

2

Insertion, care and removal of PVC

225

3

Insertion, care and removal of arterial cannulae

464

2

Insertion, care and removal of urinary catheters

377

2

CG042

4

Dress code and uniform

189

2

Screening staff for TB

410

1

Laboratory handbook

Care of central venous access devices

Further procedural documents may be produced and added as necessary

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