Appendix 3
Code of Practice for the Prevention and Control of Health Care Associated Infections
The Health Act 2006
Francesca Thompson – Director of Nursing & Director of Infection Prevention & Control
Tracey Halladay - Senior Infection Control Nurse
Updated June 2008
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Areas of Performance / Areas of compliance / Actions required to achieve full compliance / Personresponsible / Date for
completion
Management, organisation and the environment
1. General duty to protect patient staff and others from HCAI
2. Duty to have in place appropriate management systems for infection prevention and control / So far as reasonably practical, patients, staff and other persons are protected against risk of acquiring HCAI through provision of suitable facilities, consistent with good practice .
Estates has prioritised the work programme to contribute to reducing cross infection
Patients presenting with an infection or who acquire an infection are identified promptly
08/09strategic objective to put the patient first and reduce HCAI
Nominated infection control leads within each Division. IC representation at Divisional board meetings.
Divisional representation at Infection Control committee and Saving lives committee.
Regular IC reports to Governance committee and performance management meetings
Infection control programme
Surveillance data and progress report regularly to Governance committee
b) Director of infection Prevention and Control post held by Director of Nursing which is in line with guidance
c)monthly reports to trust board in place and weekly executive walkabouts
d) ensure all relevant staff whose duties are directly or indirectly concerned with patients care receive appropriate training information and supervision in IC
e) a programme of audit to ensure key polices are being implemented
f) a policy addressing where relevant, admission transfer, discharge and movement of patients between department and within and between other healthcare facilities can be found in organism specific policies / a)Allocation of £300,000 capital challenge fund from DH to appropriate projects that will contribute to reducing cross infection with particular emphasis on Clostridium difficile:
- Creating of 6 additional ensuite side rooms within Medical Division
- Purchase of new commodes
- Upgrade of sluice areas
- Utilisation of co-hort ward for C diff
- Review of risk register- Facilities
- Review of assurance framework against Code of practice
- Introduce quarterly matron reports to the board
Further enhancement and evaluation of tool
a)08/09 National Contract/operating policy/ Clean safe care
Purchase and install IT surveillance package
Recruit surveillance analyst to ICT
c) Complete IC annual programme 08/09 and take to trust board
Trust board approval of IC annual programme and IC infrastructure
Complete IC annual report and take to trust board
d)Implement annual updates for senior medical staff
Review training for volunteers and contractors
Ensure that infection control training attendance is monitored and include compliance as a key performance measure for infection prevention and control reporting
e) annual audit programme 08/09 to trust board
(Note include NICU and patient movement at divisional levels)
f)include relevant information within organism specific policies
Review guidance for operational site team and review of nursing documentation to ensure relevant information included for patient transfer and discharge. To include an infection control risk assessment during the admission process. / T Halladay/M Newton/S Good child
A House
T Halladay/M Newton/S Good child
S Goodchild/J Scott
F Thompson/J Scott
F Thompson
A Massey
A Massey
J Martin
T Halladay/ICT
Y Pritchard
T Halladay
F Thompson
F Thompson
S Meisner
Y Pritchard
Assistant DNs/Divisional Chairs/ICT
F Thompson
T Halladay/R Eliot
D Meyers/A Plaskitt / completed June 07
Completed
Ongoing
Ongoing
Feb 08
March 08
June 08
June 08
July 08
March 08
System live in Jan 08
Advertise June 08
March 08
April 08
June 08
May 08
Sept 08
April 08
March 08
July 08
3. Duty to assess risks of acquiring HCAI and to take action to reduce such risks / All NHS bodies must ensure that it has:
a) made a suitable and sufficient assessment of the risk to patients in receipt of healthcare with respect to HCAI
b) identified the steps that need to be taken to reduce or control those risks
c) record its findings in relation to items a) and b)
d) implemented steps identified
e) appropriate methods in place to monitor risks of infection such that it is able to determine whether further steps need to be taken to reduce or control HCAI / a & b) MRSA and C difficile improvement programmes in place and monitored. Programmes include targeted actions and audit programmes.
Assurance of compliance with S4BH and NHSLA / Saving lives Committee/Infection control committee/C diff working group
T Halladay/P Russell/ V McHale/F Thompson / Bi monthly
Monthly
March 08
4. Duty to provide and maintain a clean and appropriate environment for healthcare (This includes the fabric of the building and related fixtures, fittings and service such as air and water supplies) / An NHS body must, with a view to minimising the risk of HCAI, ensure that:
a) there are policies for the environment which make provision for liaison between the members of any infection control team and the persons with overall responsibility for facilities management
b) it designates lead mangers for cleaning and decontamination of equipment used for treatment
c) all parts of the premises in which it provides healthcare are suitable for the purpose, are kept clean and are maintained in good physical repair and condition
d) the cleaning arrangements detail the standards of cleanliness required in each part of its premises and that a schedule of cleaning frequencies is publicly available
e) the cleaning arrangements detail the standards of cleanliness required in each part of its premises and that a schedule of cleaning frequencies is publicly available
f)there are effective arrangements for the appropriate decontamination of instruments and other equipment
g) the supply and provision of linen and laundry supplies reflects health Service Guidance HSAG(95)18
h) clothing worn by staff when carrying out their duties (including uniforms) is clean and fit for purpose / a)Review Legionella Policy
b) Ratify cleaning policy
c)Review of capital planning programme 07/08/09
d)Cleaning schedules to be posted in areas that are easily accessible to patients and visitors to the hospital
e)Deep clean spend £200k spend
f)System to be put in place to monitor the effectiveness of cleaning of frequently touched equipment between patients
Bench top steriliser in the Mortuary – ensure that a risk assessment has been carried out. Staff using the steriliser must be trained and assessed as competent. Validation and periodic testing must be carried out.
g)Uniform contract/pilot date to be set / H&S Manager/
Director of Facilities
Manager/ICT Facilities
Director of Facilities
M Newport
M Newport
Matrons/Ward sisters
John Travers
Alan Farnsworth / March 08
April 08
Feb 08
June 08
March 08
July 08
July 08
March 08
5. Duty to provide information on HCAI to patients and the public / All NHS bodies must ensure that it make suitable and sufficient information available
a)to patients and the public about the organisations general systems and arrangements for preventing and controlling HCAI
b) to each patient concerning any particular considerations regarding the risks and nature of any HCAI that are relevant to their care and, any preventative measures relating to HCAI that a patient ought to take after discharge / a)Evaluate revised visitors arrangements
Review ICT board in Atrium for content
b) Develop strategy for patient choice regarding infection rates
Ensure relevant patient information leaflet available for each relevant policy / N Howard/F Thompson
Y Pritchard/F Thompson/T Hegarty
Y Pritchard/ICT/ PALS / April 08
June 08
Ongoing
6. Duty to provide information when a patient moves from the care of one healthcare body to another / An NHS body must ensure that it provides suitable and sufficient information on each patients infection status whenever it arranges for a patient to be moved form the care of one organisation to another so that any risks to the patient and others from infection may be minimised / Review of nursing discharge documentation
Review of MRSA bacteraemias and care pathways through collaborative PCT/RUH meetings / D Meyers/
A Plaskitt
ICT/DIPC/PCT / July/August 08
Monthly
7. Duty to ensure co-operation / An NHS body must, so far as reasonably practicable, ensure its staff, contractors and other involved in the provision of health care co-operate with it, and each other, so far as necessary to enable the body to meet its obligations under this code / Approve IC code of practice for contractors / D Meyers/D Robinson/A House / Complete
8. Duty to provide adequate isolation facilities / An NHS providing in-patient care must ensure that it is able to provide or secure the provision of adequate isolation facilities for patients sufficient to prevent or minimise the spread of HCAI / Review provision for negative pressure facility
Site development plan to increase isolation facilities
Review of MAU function and design
Daily review of patients with suspected infections admitted to MAU
Audit of ring fenced orthopaedic beds / Director of Facilities
Diane Fuller/
FrancescaThompson
Y Pritchard/ICT
Jan Lynn / April 08
February 08
Ongoing
May 08
9. Duty to ensure adequate laboratory support / An NHS body must ensure that if services are provided by a microbiology laboratory in connection with the arrangements it makes for infection prevention and control, the laboratory has in place appropriate protocols and that it operates according to the standards from time to time required for accreditation by Clinical Pathology Accreditation (UK) Ltd. / Review of laboratory services from HPA lab Bristol required in line with MRSA screening policy / J Travers / Complete
Clinical Care Protocols
10. Duty to adhere to polices and protocols applicable to infection prevention and control / Policies
The following core policies must be in place:
a)Standard universal precautions
b)Aseptic technique
c)Major outbreaks of communicable infection
d)Isolation of patients
e)Safe handling and disposal of sharps
f)Prevention occupational exposure to blood borne viruses including prevention of sharps injuries
g)Management of occupational exposure to BBVs and post exposure prophylaxis
h)Closure of wards, department and premises to new admissions
i)Disinfection policy
j)Antimicrobial prescribing
k)Reporting HCAI to the HPA as directed by the DH
l) Control of infection with specific alert organisms taking account of local epidemiology and risk assessment. These must include as a minimum, MRSA, CJD, Clostridium difficile, / Annual programme for policy review contained in infection control programme 08/09
b)Aseptic non touch technique updates
c) Debrief from major norovirus outbreak
d)Audit of isolation policy – implement new signage
j) appointment of consultant antimicrobial pharmacist
l) policies in progress –ESBL, revised MRSA policy / T Halladay/S Meisner
K Purser/ANTT group
F Thompson/D Fuller
D Meyers
R Brophy
S Meisner
S Smith / March 08
June 08
Feb 08
June 08
Back out to advert June 08
June 08
June 08
Healthcare workers
11. Duty to ensure, so far as reasonably practicable, that healthcare workers are free of and are protected form exposure to communicable infection during the course of their work, and that all staff re suitable educated in the prevention and control and HCAI / a)occupational health service: that all staff can access relevant occupational health services
b)occupational health polices: there are occupational health polices for the prevention and management of communicable infections in healthcare workers
c) induction and training: prevention and control of infection is included in induction programmes of new staff and in training programmes for all staff
d)education for existing staff: there is a programme if ongoing education for existing staff (including support staff, locum staff and staff employed by contractors)
e)updating staff: there is a record of training and updates for all staff
f)the responsibilities of a member of staff for prevention and control of infection are reflected in their job description, any personal development plan or appraisal / b) Occupational health team to ratify Staff Health policy / Colin Payton / March 08
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