Infection Prevention and Control. Policy and Procedures

Infection Prevention and Control Policy and Procedures Version: Owner: Lead: Approved By: Date of Approval: Ratified By: Date Ratified: Review Date: ...
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Infection Prevention and Control Policy and Procedures

Version: Owner: Lead: Approved By: Date of Approval: Ratified By: Date Ratified: Review Date: Target Audience: Policy ID:

2.0 Medical Director/Director of Infection Prevention and Control Assistant Director – Health, Safety & Risk Strategic Infection Prevention and Control Committee (IPCC) January 2009 Not required May 2011 All YAS Staff & Stakeholders as identified Issued by Asst Dir Health, Safety & Risk

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Contents Section

Page

1. Introduction 2. Purpose/Rationale 3. Duties and Responsibilities 4. Information Sharing 5. Training Requirements 6. Guidance associated with the policy 7. IP&C Assurance Framework 8. Health Act 2006 Core Clinical Care Protocols 9. Process for Monitoring Compliance and Effectiveness 10. Equality Impact Assessment

3 3/4 4/7 6 7 7/8 8 8 8/9 10

Appendices Appendix 1 - Role of Director of Infection Prevention and Control (DIPC)

11/12

Appendix 2- DIPC Annual report content

13/14

Appendix 3 - documents relating to Clinical Care Protocols

15

Appendix 4 - further existing documents, requiring no revision

15

Appendix 5 – documents requiring revision

15

Appendix 6 - detailed requirements of the IP&C Audit Programme

16

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1.

INTRODUCTION

1.1

This corporate policy and its associated sub policies; protocols and guidance notes, as listed in the Appendices, form the YAS strategic policy guidance relating to Infection Prevention and Control (IP&C).

1.2

Financially, as reported by the National Audit Office (NAO 2000), Health Care Associated Infection HCAI are estimated to cost the NHS £1 billion per annum and affect nine percent of hospital patients. Since the publication of the audit findings, the Department of Health has published various guidance documents to try to address the problem and reduce the number of HCAI (Getting Ahead of the Curve, Winning Ways, Towards Cleaner Hospitals and Lower Rates of Infection, Saving Lives, Essential Steps to Safe Clean Care).

1.3

The most recent document came into effect in January 2008, The Health Act 2006 – Code of Practice for the Prevention and Control of Health Care Associated Infections (DH 2008), hereafter called “the Code”. This policy helps National Health Service (NHS) bodies (including Ambulance Trusts) to plan and implement the prevention and control of HCAI.

1.4

The policy provides criteria to ensure patients are cared for in a clean environment, with the risk of HCAI kept to a minimum.

1.5

Failure of Yorkshire Ambulance Service (YAS) to comply with the criteria can result in the Healthcare Commission issuing an Improvement Notice, or place the Trust on “special measures”.

1.6

Additionally, the Trust needs to comply with the current Healthcare Commission Standards for Better Health and NHS Litigation Authority Clinical Negligence Scheme for Trusts and Risk Pooling Scheme for Trusts (CNST/RPST).

1.7

Infection Prevention and Control information is available via the YAS Internet portal and is regularly updated

2.

PURPOSE

2.1

All NHS Trusts have a statutory duty to comply with The Code, which stipulates; “so far as reasonably practicable, patients staff and other persons are protected against risks of acquiring healthcare acquired infections (HCAI’s) through the provision of appropriate care, in suitable facilities, consistent with good clinical practice “ YAS has responsibilities under the Code (2008), to ensure

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o effective management arrangements are in place for IP&C issues o clinical care protocols address IP&C issues o health care workers are protected from exposure to communicable infections during the course of their work 2.2

Compliance against “the code” will be via the production of quarterly update reports to the Trust board

2.3

The code will constitute part of the YAS IP&C Assurance Framework

2.4

It is the intention of this document to reduce the risk of patients and staff acquiring HCAI.

2.5

This policy is supported by a number of Appendices offering guidance; information; supporting policies and protocols relating to IP&C issues

3.0

DUTIES AND RESPONSIBILITIES

3.1

Trust Board

3.1.1 The Trust Board is collectively responsible for minimising the risk of infection and must have mechanisms to ensure sufficient resources are available to secure effective prevention and control of HCAI. These include implementing an appropriate assurance framework, IP&C infrastructure and IP&C training; auditing and monitoring programme. 3.2

Strategic Infection Prevention and Control (IP&C) Committee

3.2.1

The IP&C Committee is responsible for providing assurance to the Board over all aspects of Infection Prevention and Control (see Section 7 below) and reports to the Board on a quarterly basis.

3.2.2

This committee is the technical centre of expertise on this topic and it meets not less than five times per annum.

3.2.3

The committee operates under approved terms of reference and ensures that they address all appropriate IP&C topics and that staff groups are appropriately represented

3.2.4

The minutes from IP&C committee are presented to the Integrated Governance Committee for review, after approval by the Strategic IP&C Committee.

3.3

Chief Executive

3.3.1 The Chief Executive will ensure that infection prevention and control

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requirements are included in the portfolios of all Executive Directors and Non Executive Directors employed by YAS 3.4

Directors

3.4.1 Directors will ensure that each manager’s responsibilities for infection prevention and control are reflected in their job descriptions, personal development plans or appraisal. 3.4.2 The Medical Director is the nominated Director of Infection Prevention and Control (DIPC) and this role will be included in their job description – see Appendix 1 3.4.3 The role of DIPC is explained in the DH document titled DIPC role profile April 2008 which is shown in Appendix 1 3.4.4 The DIPC is required to produce an Annual Report covering the topics shown in Appendix 2. 3.5

Assistant Directors; Managers and their Support Staff

3.5.1 All Assistant Directors; Managers and Support staff will lead by example and adopt good practice at all times in order to ensure the implementation of effective infection prevention and control across the Trust. 3.5.2 In particular, they are responsible for: • • •

• • • •

ensuring that the infection prevention and control policy is adhered to within their area of responsibility ensuring infection prevention and control risks are assessed and reduced so far as reasonably practicable for activities under their control facilitate and record the required infection prevention and control training and updates of staff under their supervision to enable them to carry out their roles safely and promote the YAS IP&C e-learning modules coordinating and monitoring all aspects of infection prevention and control and reporting matters of concern to the appropriate responsible person or their line manager communicating infection prevention and control messages to staff on a regular basis particularly relating to actions taken post incident reports or as part of lessons learned ensure that staff members responsibilities for infection prevention and control are reflected in their job descriptions, personal development plan or appraisal promote the reporting of IP&C related incidents in line with current YAS procedures

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3.6

Infection Prevention and Control Nurse (IPCN)

3.6.1

The IPCN will lead by example and adopt good practice at all times in order to ensure the implementation of effective infection prevention and control across the Trust.

3.6.2 The IPCN will provide advice and practical assistance in all matters relating to infection prevention and control. In particular their responsibilities will include: • • • • • • •

3.6

ensuring audit arrangements are adequate and completed on an annual basis to consider compliance with current year requirements and shape the future direction of infection prevention and control. maintaining suitable recording arrangements for infection prevention and control purposes ensuring the promotion of infection prevention and control in a proactive manner supplying appropriate information in a timely manner encouraging reporting and monitoring of all infection prevention and control incidents and injuries to staff or other affected parties co-operating with Staff Side Worker representatives developing infection prevention induction training, training and updates for staff (in conjunction with Education and Development Department when appropriate) and providing training as necessary

All Employees

3.6.1 Every employee has a personal responsibility for infection prevention and control and has a duty to: • • • • • • • •

demonstrate good infection prevention and control and hygiene practice comply with the requirements of all appropriate Appendices contained within this document undertake appropriate IP&C training and e-learning as identified in their Personal Development Review adopt standard (universal) precautions to minimize the transmission of infection including blood-borne viruses ensure that if any additional infection prevention and control precautions are necessary, these are documented in patient’s records correctly use Personal Protective Equipment provided by the Trust not to misuse equipment or items provided in the interest of infection prevention and control co-operate with management in reviewing policies and procedures regarding infection prevention and control and for making them effective

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• •

3.7

ensure responsibilities for infection prevention and control are reflected in their job descriptions, personal development plans or appraisal report all infection prevention and control incidents, near misses, hazards, work related illnesses or injuries, however minor, to their supervisor and ensure that these are documented properly

Consultation and Communication with Stakeholders

3.7.1 YAS will consult internally with Staff Side colleagues and appropriate specialist advisers during the course of preparation and implementation of this policy and associated guidance documents 3.7.2 YAS will consult with other NHS organisations and key service commissioners as necessary when developing and implementing the requirements of this policy and guidance 3.7.3 YAS will consult with external stakeholders via the Equality Impact Assessment contained within this document 4

INFORMATION SHARING

4.1

IP&C information is shared between YAS and its Occupational Health (OH) providers in order to protect staff and patients from risks;

4.2

IP&C information is shared with the Health Protection Agency; Commissioners of YAS Services; Enforcement Agencies and other NHS partner organisations in order to comply with legal requirement or reduce the potential risks associated with the transmission of HCAI

4.3

Suitable and sufficient information about YAS general systems and arrangements for preventing HCAIs have to be provided to patients and members of the public in compliance with the Code requirements.

5

TRAINING REQUIREMENTS

5.1

All new staff must receive IP&C training at Corporate or local induction.

5.2

All existing staff to be trained in line with the YAS training needs analysis/structured training plan and there has to be a programme for continued education on IP&C

5.3

Records of training have to be kept up to date

5.4

Training will also be provided for agency workers; volunteers and contractors staff

6

GUIDANCE ASSOCIATED WITH THIS POLICY

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6.1

The guidance associated with this policy and their projected timescale for delivery are shown in Appendices 3 to 6 attached

7

IP&C ASSURANCE FRAMEWORK

Assurance over infection prevention and control is provided to the Trust Board as follows: 7.1

The IP&C Committee establishes any work plan required in addition to the requirements of the Code contained within the Health Act at its planned meetings and monitors progress against it.

7.2

The IP&C committee develops and monitors progress against the action plan arising from compliance with the Code.

7.3

The IP&C committee monitors compliance of progress against any action plan arising from the YAS Care Quality Commission registration for a HCAI licence to operate.

7.4

The IP&C Committee reports on progress on all relevant matters relating to infection prevention and control to the Board on a quarterly basis, including an annual Year End report.

7.5

The DIPC makes quarterly presentations and an annual report to the Trust Board and the IPC Committee relating to compliance against the requirements of the Code. See Appendix 2 for details of what is covered in the annual report.

7.6

The IP&C Committee establishes an annual audit programme, according to the requirements set out in Appendix 6 and monitors progress against it.

7.7

The IP&C committee receives reports on the findings of all audits or initiatives undertaken relating to IP&C issues.

7.8

There is a review of IP&C incidents and risks including details relating to alert organisms appropriate to an ambulance service at each IP&C committee meeting.

7.9

The IP&C committee receives reports relating to any actions taken to resolve infection problems or outbreaks relevant to YAS or to highlight the lessons learned from any Serious Untoward Incidents (SUIs).

8

HEALTH ACT 2006 – CORE CLINICAL CARE PROTOCOLS

8.1

Appendix 3 lists approved documentation of YAS policies and/or procedures which relate to each of the core clinical care protocols which apply to Ambulance Trusts.

9

PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS

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9.1

Compliance will be monitored across all levels of YAS by observational technique; self assessment questionnaires, e learning management systems and Training School procedures as indicated in Appendix 6 attached.

It specifically includes the following Topic Provision of quarterly reports to Trust Board

Responsibility AD HS&R IP&C Nurse

Key Indicator Progress made against Board approved plan

Provision of reports to Strategic IP&C Committee five times per annum

AD HS&R IP&C Nurse

Progress made against approved plan

Devise a range of auditing tools and provide training for relevant Managers and staff to use them.

IP&C Nurse

Managers undertaking annual IP&C audits of their work locations

Evaluate current IP&C training course content

Training School

Statistically sample a range of IP&C indicators in accordance with British Standard 6001:2006

AD HS&R IP&C Nurse HS&R Team

Service Managers

IP&C Nurse

25% of all training courses audited per annum Establish benchmark percentage compliance factor in accordance with the relevant BS

Outcome Board receive assurance of satisfactory progress against agreed objectives Committee receive assurance of satisfactory progress against agreed objectives Improvement in IP&C standards across YAS

% of courses audited meet current legal and DH/NPSA requirements Informs NHS Ambulance benchmarking initiative and sets year on year indicator for improvement

Compliance will be monitored by observational technique; slef assessment questionnaire

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10.

EQUALITY IMPACT ASSESSMENT

This policy has an Equality Impact Assessment, which can be found on the YAS Library site.

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Appendix 1 Director of Infection Prevention and Control (DIPC) 1

Role Summary Main Responsibilities of a DIPC

The DIPC will have the executive authority and responsibility for ensuring the implementation of strategies to prevent avoidable healthcare associated infections (HCAIs) at all levels in the organisation. The DIPC will be a highly visible, senior, authoritative individual who will provide assurance to the Board that the systems are in place and the correct policies and procedures are adhered to across the organisation to ensure safe and effective healthcare and to comply with the Health Act 2006. The DIPC will be an effective leader who will enable the organisation to continuously improve its performance in relation to HCAIs. The DIPC will be the public face of infection prevention and control and will be responsible for the Annual Report which should provide details of all aspects of the organisation’s infection prevention and control programme and should include publication of HCAI data for the Trust. Although not generally a unique, full-time appointment, the DIPC must have designated time to deliver the requirements of the role. Each NHS organisation should define and agree the time required to fulfil the role of DIPC within their own organisation. 2

PRIMARY DUTIES 

Have corporate responsibility for infection, prevention and control throughout the Trust as delegated by the Chief Executive.



Report directly to the Chief Executive and assure the Trust Board on the organisation’s performance in relation to HCAIs providing, regular reports including an Annual Report.



Be responsible for the development of strategies on infection, prevention and control and oversee implementation.



Act on legislation, national policies and guidance ensuring effective policies are in place and audited.



Provide assurance to the Board that policies are fit for purpose.



Attend Board meetings to report on infection prevention and control issues and to ensure infection prevention and control consideration in other operational and developmental decisions of the Board.

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Provide leadership to the infection, prevention and control programme in order to ensure a high profile for infection prevention and control across the organisation.



Ensure that the requirements of decontamination guidance are in place and adhered to through implementation of appropriate policies.



Ensure public and patient involvement in infection, prevention and control.

3

MANAGEMENT/LEADERSHIP 

Challenge professional and organisational barriers, where appropriate, in the interest of the public, staff and patients to reduce HCAIs.



Influence the allocation of resources required to minimise the risk of HCAIs.



Ensure infection prevention and control is included in all job descriptions and job plans, is a mandatory component of CPD and is included in the appraisal of all clinical staff.

4

LEARNING & DEVELOPMENT 

Influence the development and provision of education and training in relation to infection, prevention and control and oversee the audit of its uptake by staff.



Encourage and oversee participation in relevant appropriate research opportunities.

5

CLINICALGOVERNANCE/AUDIT/RESEARCH 

Be a Member of Clinical Governance Committee or equivalent.



Develop a robust performance management framework for infection, prevention and control that minimises healthcare associated infections.



Ensure effective surveillance systems are in place with timely feedback to clinical services.

6

COMMUNICATION 

Utilise a range of strategies to support effective communication within the organisation and across the wider health and social care economy in relation to infection prevention and control.



Provide effective communication of the Trust’s infection prevention and control activities and HCAI records to the general population and the local press/media.

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Appendix 2 - DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT 1) Executive summary - Overview of infection control activities in the Trust  Organisation  Activities  Infection Prevention and Control Action Plan for the year  Progress made towards approved IP&C initiatives 2) Description of IP&C arrangements  IP&C team  IP&C committee  Reporting line to the Trust Board  Links to Clinical Governance/Risk Management/Patient Safety 3) DIPC reports to the Trust Board – summary  

Annual Action Plan Board decisions

4) Budget allocation to IP&C activities  Staff  Training  Equipment and Consumables  Vehicle Make Ready activity 5) Root Cause Analysis requests and findings from Acute Trusts   

Trends in HCAI statistics Untoward incidents Goals identified locally

6) Hand hygiene and Aseptic protocols  Implementation of ‘cleanyourhands’  Timing  Coverage in Trust  Future plans 7) Decontamination  Arrangements o Internal arrangements o Third party premises o Contracted out services  Audit  Incidents/failures investigated

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8) Cleaning services  Management arrangements (in-house or contracted out)  Monitoring arrangements  Budget allocation  Clinical responsibility  Clinical access  User satisfaction measures 9) Audit  Extent of audit programme  Reasons for audit focus  Adoption of ICNA audit tool or alternative  Antibiotic prescribing (report from Antimicrobial Pharmacist)  Changes and benefits as a result of audit 10) Targets and outcomes  

Healthcare Commission self-assessment Local targets

11) Training activities     

Induction for all staff CPD for all staff CPD for clinical staff For IP&C specialists For DIPC

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Appendix 3 - YAS documents approved by the Strategic Infection Prevention and Control Committee and their link to the Health Act 2006 Clinical Care protocols 1 2 3

4

5

6

Standard Universal Precautions – Clinical Care protocol 10a: Standard (universal) infection control precautions Aseptic techniques – Clinical Care protocol 10b: Aseptic technique Waste disposal policy and guidance – safe handling and disposal of sharps – Clinical Care protocol 10e: Safe handling and disposal of sharps Management of Inoculation Injuries and Management of Sharps Injuries – Clinical Care protocol 10f: Prevention of occupational exposure to blood-borne viruses (BBVs), including prevention of sharps injuries & Clinical Care protocol 10g: Management of occupational exposure to BBVs and post exposure prophylaxis Cleaning and Decontamination of vehicles and medical equipment and A-Z of decontamination of specific devices – Clinical Care protocol 10i: Disinfection policy Reporting Health Care Associated Infections to the Health Protection Agency – Clinical Care protocol 10k: Reporting HCAI to the Health Protection Agency as directed by the Department of Health

Appendix 4 – additional YAS documents approved by the Strategic Infection Prevention and Control Committee 1 2 3 4 5 6 7 8

Hand hygiene – to incorporate bare below the elbows requirements Blood borne viruses Chicken pox and shingles C Difficile Care of Infected Patients Care and maintenance of pillows, mattresses, seats and stretcher covers Norovirus Methicillin Resistant Staphylococcal Aureus

Appendix 5 – documents requiring revision by IP&C Committee 9 10 11 12 13 14 15 16 17 18

New buildings and existing facilities adaptation guidance Severe Acute Respiratory Syndrome Scabies Tuberculosis Headlice Fleas Meningitis Premises cleaning Planned preventative maintenance and pest control Laundry policy including Uniforms and Workwear

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Appendix 6 – The detailed requirements of the IP&C audit programme 1. Audit of compliance against premises cleaning KPIs produced by Fleet 2. Audit of compliance against vehicle and equipment KPIs produced by Fleet 3. Compliance against the requirements of the code in line with the amended Health Act requirements 4. Monitoring the numbers of staff formally trained in IP&C compliance in a classroom setting or at induction 5. Monitoring the numbers of staff trained in IP&C via the YAS e-learning protocol 6. Biennial inspections of YAS workplaces by Health, Safety & Risk staff relating to IP&C issues and compliance 7. Hand hygiene audit twice per annum 8. Compliance with and actions taken relating to any MHRA or NHS Estates or NPSA alerts issued each year 9. The creation and removal of data flags within control re community outbreaks identified by YAS stakeholders 10. Training course modification to reflect changes in IP&C advice/practice 11. Training course modification to reflect any lessons learned from SUIs or MRSA Root Cause investigations.

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