Infection Prevention & Control Annual Plan

Infection Prevention & Control Annual Plan 2014-2015 To comply with the Health and Social Care Act 2008 (updated 2010) Action has slipped Action is n...
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Infection Prevention & Control Annual Plan 2014-2015 To comply with the Health and Social Care Act 2008 (updated 2010)

Action has slipped Action is not yet complete but is on track Action has been completed

Issue / Problem

Actions

Lead

Timeline

Trust Board Objectives

The Board will monitor the Trust compliance with the Health and Social Care Act 2008.

Page 9 of 22



The Board, TLEC and Infection Prevention and Control Panel (IPCP) will receive the Annual IPC Report.

DIPC

June 2014



The Board will receive Infection Prevention & Control (IPC) updates and key indicators at each Board Meeting

DIPC

Monthly



The Board will receive reports and risks associated with IPC via the IPCP and Quality and safety group

DIPC

Quarterly



The Board will receive information relating to assurance on compliance with the Code of Practice, CQC outcome 8 and key indicator targets via the Quality and safety group and challenge concerns in relation to compliance

DIPC

Quarterly

Progress/ Assurance

RAG

Divisional Objectives: •

• •

ADIPC HoN/HoM

IC risks are fed into Divisional Risk Registers and reviewed monthly. All staff attend Trust induction and mandatory update sessions Lessons from IC SIs/outbreaks are reviewed monthly, reported to the IPCP and Quality and safety group and acted upon. Monitoring of Divisional Infection Prevention & Control associated audits e.g. antibiotic compliance, action plan to be developed and presented to the IPCP All High Impact interventions inc hand hygiene scoring less than 95% with formulate an action plan with evidence of actions taken and returned to IP&C Team, this which will be discussed at the next local HCAI Any member of staff persistently not complying to hand hygiene policy or high impact intervention will be named on audits for review and escalation as required

Risk leads HoN/HoM IPC leads HoN/HoM HoN/HoM



Participate in the Test Your Care audits

HoN/HoM



Isolate patient with an infection e.g diarrhoea within two hours (DH) to reduce the risk of cross infection



Incidence of failure and ability to isolate reported to clinical risk will be escalated to IPCP through a quarterly report.

Ward/Dept Manager/ Matron Risk Manager

• • •







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Each division will present their divisional action plan as per rolling programme to the IPCP

IPC leads/ HoN/ HoM HoN/HoM

Each division will attend bi weekly Local Healthcare Associated Infections (Local HCAI) and update their divisional action plan. The minutes are escalated to IPCP

• All divisions to ensure that the reduction of healthcare associated infections is a priority.

Each Division will table clinical issues and exception reports for the Quality and Safety group actions to the IPCP

Monthly

Quarterly

Bi weekly

Monthly Ongoing Ongoing

CD

Ward/Dept Manager/ Hon/HoM Ward/Dept Manager/ HoN/HoM

Quarterly Ongoing

Ongoing

Ongoing Monthly Ongoing Quarterly

• • •









• •

Patient in isolated in side room for infection control reasons should have dedicated equipment for use e.g disposable BP cuffs, hoist slings. Equipment decontamination /cleaning schedules that specifies cleaning standards for equipment such as commodes, BP cuffs are in place 6 monthly environmental audits to ensure that all ward areas are well maintained and appropriately managed to reduce the risk of infection Refurbishment program to be developed by each ward and in conjunction with estates Divisions take ownership of RCA and are completed in a timely manner



Surgical division to fulfil the Mandatory SSISS



Women and Children division to look into C- section SSIS

• •

• •

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There should be evidence of a rolling programme for equipment replacement, to ensure all the equipment is fit for purpose For all new equipment to be purchased , cleaning instruction for the equipment should be obtained from the manufacturer and these submitted to IPCT for approval before a purchase is agreed. Patient equipment e.g Commodes, BP cuffs must be cleaned in between each patient use

Ward/Dept Manager/ Hon/HoM Hon/HoM Matron

May 2014 Ongoing

Ward/Dept Manager/ Matron Ward/Dept Manager/ Matron Ward/Dept Manager/ Matron Ward/Dept Manager/ Matron HoN/Head of estates HoN

Ongoing

HoN (surgery) HoM

Quarterly

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing Ongoing

Q3

Estates and Facilities; Operational Head of Monthly Facility On going Assure quality of environmental cleanliness/ audit of the clinical areas Heads of As per Ensure deep cleans are carried out as per schedule (every quarter and any estates work is carried out prior to Facilities & schedule Estates the deep clean Head of As per PLACE inspection interfaced with 15 “Steps” Facility schedule







Develop a schedule for refurbishment of clinical areas and to involve Infection Prevention and Control in all building works (from planning to finish of the building works) Availability of a decant ward so as Deep clean can be carried out

Director of Facility and Estates

On going

COO

On going

Minutes and papers from the Water Safety Group meetings to be tabled at the IPCP

Head of Facilities

Monthly

The Infection Prevention & Control Team is there to support, educate, train, advise, carry out surveillance and provide leadership to ensure the acquisition and spread of pathogenic microorganisms is kept to a minimum.

Core Duty

1. Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them.

Actions • • • • • • •

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Provide reactive service to meet needs of incidents/enquiries/outbreaks Work proactively with multi-disciplinary staff and departments to reduce risk of HCAI Identify and inform IPCP of any risks associated with IC resources and ability to provide service Work collaboratively with Clinical Commission Group, Trust Development Authority & the Hertfordshire Health Economy Up to date policies in place with audit schedule to monitor compliance Submit a business case for an Infection Surveillance software Recruit 3 more CNS to the team to ensure there is enough recourses to support the delivery of the IPC annual plan

Lead

Timeline

ADIPC

On-going

ADIPC ADIPC ADIPC ADIPC ADIPC ADIPC

May 2014

Progress and Assurances

RAG

Core Duty

2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

Actions •

• •



• • •

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Lead

Ensure audits are carried out annually and provide Trust wide compliance results to IPCP. Any clinical areas achieving less than 95% compliance to produce a remedial action plan. The completion of action plans managed through Local HCAI meetings. Audits by the Infection Prevention and Control nurses:

Lead Nurse IP&C with Ward/ unit Manager

 Decontamination of patient equipment  Clinical environment and practice  Personal Protective Equipment  Management of Linen  Isolation Precautions  Management of sharps Participate in PLACE / 15 Steps Continue to advise backlog maintenance and Capital Project Boards on infection prevention & control in the built environment and general refurbishment projects Infection Prevention & Control Team and HoN/HoM/Matron, to monitor standards and identify any potential risks through monthly rounds. Review standards of cleaning monthly with contract monitoring Team and Facilities site manager Support all clinical areas at times of outbreaks in managing Terminal/Deep clean at end of outbreak Audit availability of hand hygiene facilities

ADIPC ADIPC ADIPC ADIPC ADIPC/ Lead Nurse IP&C ADIPC

Timeline Ongoing Ongoing Ongoing monthly 6 monthly As per audit schedule yearly Ongoing Ongoing Monthly Monthly

ADIPC On going Lead Nurse

Sept 2014

Progress and Assurances

RAG

Core Duty

3. Provide suitable accurate information on infections to service users and their visitors

4. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.

Actions •

Maintain information leaflets for patients and visitors on • Ensure all patient and public information leaflets are current and available on the Trust website • Maintain information leaflets for contractors/volunteers/bank & locum staff • Attend Trust AGM with supporting display for the public • Review all Hand hygiene posters and leaflets visible encouraging visitors and patients to use facilities and challenge staff • Review hand gel and soap supplier, public signage • Participate in National Hand Hygiene Awareness Days. • Participate in international Infection Prevention and Control Week

• • • •

5. Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.







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Lead Lead Nurse IPC Lead Nurse IPCLead Nurse ADIPC/ Lead Nurse IPC

Timeline

Progress and Assurances

June 2014

Sept 2014 June 2014May 2014 October 2014

Maintain up to date polices and guidelines for Infection Prevention on the Trust intranet. Review all Staff & Patient Information leaflets are all current and accessible on the Trust intranet. Inform G.P. if patients are discharged before MRSA results are known and new MRSA Inform G.P of admitted patients indentified to have Clostridium difficile

ADIPC

On going

Lead IP&C Nurse

Ongoing

All patient `s microbiological results are managed as a priority within the IP&C team. Patients are visited on the wards and ward staff liaised with ensuring that staff understand and are aware of the correct infection prevention & control measures required for that particular organism Ensure timescales for RCA/PIRs reporting are met and corrective actions/learning shared across Divisions through Local HCAI meeting Inform all appropriate clinic staff of elective MRSA and

Lead Nurse IPC

Lead IP&C Nurse

Ongoing ADIPC ADIPC

RAG



• • •

6. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.









• • • •

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emergency screening results. Review and provide Trust Board monthly elective and emergency MRSA screening compliance percentages including year to date. Audit MRSA and Clostridium difficile care pathways and feedback results to clinical areas, HoN/HoM and IPCP Mandatory update to includes outbreak management and isolation Inform bed management of any outbreaks (e.g of Norovirus or any other infection) in local care home and NHS Trusts

Lead Nurse IPC

Review and update IPC Training schedule for all Trust employees including contractors and volunteers : Mandatory, Induction; Venepuncture & intravenous cannulation; Ad hoc related to DH & local initiatives

Lead Nurse IP&C

Review formal training on peripheral line insertion/aseptic technique/blood culture taking and ongoing management to be included in Education /training review All clinical staff in the Out Patient Departments/ Phlebotomy Radiology and Anticoagulant Clinic staff undertake annual hand hygiene refresher training and assessment. All outpatient departmental staff inserting intravenous lines undertake annual aseptic technique refresher training and assessments All clinical staff involved in the insertion of urinary catheters to be reassessed for procedural aseptic technique Link Practitioner Educational meetings – maintaining records of attendance and feedback at local HCAI meetings Make blood culture training DVD Blood culture taking training for doctors new to the Trust and other staff that take blood cultures

Lead Nurse/ADIPC

As per audit schedule

ADIPC/HoN/HoM Ongoing

Lead Nurse IP&C/

Annually

ADIPC

Annually Annually

Lead Nurse IP&C/

Annually

ADIPC

Lead Nurse IP&C Nurse Vascular Access Lead Nurse IP&C/ADIPC

Quarterly Septembe r Ongoing June 2014

7. Provide or secure adequate isolation facilities

8. Secure adequate access to laboratory support as appropriate

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Ensure adequate isolation precautions and facilities as appropriate to prevent or minimise the spread of infections • Ongoing review of capacity within isolation ward to meet clinical need. • Isolation Policy is audited by the IPCT annually • The Trust’s capacity to comply with demands of isolation requirements will be monitored quarterly through report to IPCP from bed management • Audit side room availability inc. rooms with both neg & pos vent. • Audit Trust wide isolation capacity

• Ensure the microbiology laboratory has appropriate protocols and standard operating procedures as required for accreditation by Clinical Pathology Accreditation (UK) Ltd.

DIPC Lead Nurse IP&C

Ongoing

ADIPC/Lead Nurse IP&C Nov 2014 ADIPC

ICD/ Consultant Microbiologist

Ongoing

9. Have and adhere to policies, designed for the individual’s care and provider organisations, which will help to prevent and control infections.

Policies are updated with review dates and clearly marked up where they link to other policies both on the actual policy. Policies/guidelines to be revised – Priority to

Infection Control Doctor o

Compliance with key policies is ensured through the implementation of high impact interventions and monitored through audit.

o o

o o o o o o o o o o o o o o

10.Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.

The implementation of carbapenemase-producing Enterobacteriaceae (CPE) tool kit Blood Culture collection Prevention of Intravascular devices related infections ( combine the Peripheral Intravenous cannulation and Central venous catheter insertion and management in adults and paediatrics policies into one) Bed/mattress management Outbreak Policy Management of linen (replaces Guideline for the management of patient soiled personal clothing) MRSA ( combine all MRSA polices into one document) Ventilator Care Urinary catheter & suprapubic catheter management Decontamination – Management of blood other body fluid spillage Surveillance Policy (NEW) IP&C in the Operating Theatre Building and Renovation in hospital (NEW) Purchase, trial and loan equipment (NEW) Animals in hospital (NEW) Management arrangements for infection control (NEW) Specimen Collection and Microbiological Analysis (NEW)



Annual Gap analysis of training needs;



Review Annual training programme for all staff including contractors, locums, volunteers, bank & agency.



Audit of training uptake

Related Occupational Health policies are in date: • •

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ADIPC

Review, update and amendment of OH Clearance document. Incorporating changes to exposure prone procedure restrictions

April 2014

ADIPC ADIPC Lead Nurse IPC/TVN ADIPC ADIPC ADIPC ADIPC ADIPC ADIPC ADIPC

Lead Nurse IPC

Occupational Health Manager

Annually

• • •

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for HIV infected healthcare workers Development of a Patient group direction which would form a working schedule and guideline for immunisation Mask fit testing for staff in the required clinical areas Compliance with EU Sharps Directive

Ongoing

Health and safety manager

Ongoing