INFECTION PREVENTION POLICY

Version / 8
Name of responsible (ratifying) committee / Infection Prevention Management Committee
Date ratified / 12 May 2016
Document Manager (job title) / Associate Director Infection & Patient Safety
Date issued / 02 June 2016
Review date / 30 April 2019
Electronic location / Infection Control Policies
Related Procedural Documents / Infection Prevention Policies
Key Words (to aid with searching) / Infection prevention; Infection control; Infection control committees; Hospital hygiene; Healthcare associated infection; Cleaning; Decontamination; Hand Hygiene; Staff health and safety; Risk factors; Duties; Infection monitoring systems; Risk management; Training; Clinical guidelines

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
8 / May 2016 / Updated Team structure, Vascular Access included / IPT


CONTENTS

QUICK REFERENCE GUIDE 3

1. INTRODUCTION 4

2. PURPOSE 4

3. SCOPE 4

4. DEFINITIONS 4

5. DUTIES AND RESPONSIBILITIES 5

6. PROCESS 10

7. TRAINING REQUIREMENTS 12

8. REFERENCES AND ASSOCIATED DOCUMENTATION 13

9. EQUALITY IMPACT STATEMENT 13

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 15


QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for those involved in the process to be aware of and follow the detail of this policy.

To ensure there is a robust framework in place for the Prevention and Control of Infection, the Trust has adopted a number of key approaches

1. There are a number of core clinical protocols for Infection Prevention and Control

·  Standard Infection Prevention and Control Precautions - Standard (Infection Control) Precautions Policy

·  Aseptic Technique– Aseptic Technique Policy

·  Major outbreaks of communicable disease– Viral Diarrhoea and Vomiting Prevention and Management Policy, Control of Tuberculosis

·  Isolation of patients – Isolation Policy

·  Safe handling and disposal of sharps – Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and Management

·  Prevention of occupational exposure to blood-borne viruses including prevention of sharps injuries– Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and Management

·  Management of occupational exposure to blood-borne viruses and post exposure prophylaxis. – Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and Management

·  Closure of wards, departments and premises to new admissions. – Management of Outbreaks of Viral Diarrhoea and Vomiting, Policy for the management of MRSA and other antibiotic resistant micro-organisms

·  Decontamination of reusable medical devices – Decontamination of Reusable Medical Devices Policy

·  Disinfection

·  Antimicrobial prescribing – Antimicrobial Prescribing Policy

·  Reporting healthcare associated infections to Public Health England or local authority as directed by the Department of Health

·  Control of infections associated with specific alert organisms taking account of local epidemiology and risk assessment. – Management of Outbreaks of Viral Diarrhoea and Vomiting, Policy for the management of MRSA and other antibiotic resistant micro-organisms

2. The provision of information to patients and visitors

3. An annual Infection Prevention assurance framework, in the form of an action plan.

1.  INTRODUCTION

Portsmouth Hospitals NHS Trust (the Trust) recognises that it has a duty of care to protect patients, staff, contractors and visitors from infection and supports the need for effective systematic arrangements for surveillance, prevention and control. It is therefore committed to reducing the incidence of healthcare associated infections and, more importantly, maintaining that reduction.

For many common infections and infectious diseases, early recognition and prompt action can reduce the spread of disease, the severity of the illness and the number of people infected and Trust expects its staff to adhere to Infection Prevention and Control (IPC) Guidelines to ensure high standards of care are applied to protect patients, staff and visitors from unnecessary exposure to infection.

2.  PURPOSE

The purpose of this policy is to explain the principles of infection prevention and control and to define the responsibility and accountability of each member of staff in ensuring that those principles are adhered, so that the Trust can be assured that our prevention and control measures are robust and appropriate.

3.  SCOPE

This Policy applies to all staff, both clinical and non-clinical, employed by Portsmouth Hospitals NHS Trust, and also to all visiting staff including tutors, students, agency/locum staff and contractors.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.  DEFINITIONS

Infection Prevention and Control: processes to prevent and reduce to an acceptable minimum the risk of the acquisition of an infection amongst patients, health care workers and any others in the health care setting

Healthcare Associated Infection (HCAI): any infection that arises as a result of healthcare, regardless of the care setting. It includes hospital, primary and community care acquired infections.

Infection: when organisms in or on the body have started to multiply and/or invade a part of the body where they are not normally found. The body develops a reaction leading to disease or illness.

Cross Infection: the transfer of organisms from one person to another, this may or may not lead to illness or disease.

Colonisation: the presence of organisms in or on the body (including wounds), but without any sign of illness or disease. The body is colonised with many organisms the majority of which cause no harm and some are actually beneficial.

Communicable Disease: infection which is capable of spreading from person to person.

Spread of Infection is usually spread by one of the following means:-

·  Direct Contact: Contact with contaminated blood, body secretions or fomites particularly by staff hands that have become contaminated by body to body contact or the inanimate environment, and by transfusion of contaminated blood

·  Indirect Contact: Through equipment, medical devices or processes of care or the environment in which healthcare is provided.

·  Air Borne Spread: contaminated skin scales, aerosol spread via droplets from coughing and sneezing.

·  Vectors: third parties such as mosquitoes, ticks etc can carry infectious agents.

5.  DUTIES AND RESPONSIBILITIES

Trust Board

The Trust Board has overall responsibility for ensuring there are effective strategic, corporate and operational arrangements in place to maintain an effective infection prevention and control programme and that appropriate financial resources are in place to support that programme. To support this responsibility the Trust Board receives a monthly infection report provided by the Infection Prevention Team (IPT).

Chief Executive
The Chief Executive has overall responsibility for ensuring that there are robust processes in place to ensure effective infection prevention procedures are in place but delegates this responsibility to the Medical Director in his capacity as the Director of Infection Prevention & Control (DIPC).
The Medical Director

The Medical Director, in his role as DIPC and Chair of the Infection Prevention Management Committee, is responsible for:

·  Providing oversight, assurance and strategy on infection prevention (including cleanliness) to the Trust board

·  Reporting directly to the Chief Executive and the Board

·  Leading the Trust’s infection prevention team

·  Overseeing the implementation of local infection prevention policies and practices; measuring and assessing their impact and recommending any required changes

·  Challenging inappropriate infection prevention and control practice and antibiotic prescribing decisions

·  Set and challenge standards of cleanliness

·  Being a member of the infection prevention and antimicrobial stewardship committees and regularly attend infection prevention meetings

·  Being an integral member of the organisation’s clinical governance and patient safety teams and structures, including water safety group

·  Presenting an annual report to the Trust Board and external stakeholders, on the organisation’s position in respect to healthcare associated infections. When approved, the document will be released publicly via the Trust intranet and internet.

Infection Prevention Management Committee

The Committee, chaired by the Medical Director in his role as the Director of Infection Prevention and Control (DIPC), meets on a quarterly basis and is responsible for:

·  Discussing, approving and monitoring the Infection Prevention (IP) strategy

·  The development of IP policies, guidelines and standards

·  Setting and monitoring local priorities related to IP

·  Ensuring compliance with national standards by development and implementation of robust monitoring systems across the health community served by the IPT

·  Coordinating and monitoring IP activity across the whole health economy through the implementation of an annual programme of work, in accordance with national standards and evidence based best practice

·  Evaluating the impact of infection on service delivery

·  Directing and supporting the IPT

·  Identifying organisational learning and development requirements of Trusts across the whole health economy

·  Ensuring the effective implementation of the HCAI Plan

·  Receiving and reviewing reports from infection prevention and control projects e.g. endoscopy and theatre compliance with decontamination and IP standards; making any required recommendations to Trust Boards across the whole health economy

·  Reviewing trend analysis from the IPT, of incidences of sentinel organisms to ensure long term review and, through the Chair, taking any actions as identified by the trends

·  Receiving and reviewing reports from the IPT on adverse incidents and near misses and recommending any change in practice or policy as highlighted by those reports

·  Providing Trust Boards across the whole health economy with an annual report on activity, outcomes and recommendations for change

Serious Incident Review Group (SIRG)

SIRG provides a high level forum in which to oversee and monitor the reporting and review of serious incidents, ensuring that recommendations arising from Serious Incident investigations are implemented as required and that organisational learning has taken place. In addition the group will escalate any appropriate risks to the Risk Assurance Committee for inclusion on either the Assurance Framework or the Risk Register.

Risk Assurance Committee (RAC)

The purpose of the Risk Assurance Committee is to promote effective risk management and to establish and maintain an assurance framework and a risk register through which the Board can monitor the arrangements in place to achieve a satisfactory level of internal control, safety and quality.

CSC Governance Committees

The Committees are responsible for:

·  Receiving reports from the Learning and Development Team on staff attendance at IP training

·  Monitoring compliance with training through ESR.

·  Continual monitoring of staff attendance at IP training, to ensure compliance

·  Monitoring any adverse events and near misses associated with IP training

·  Overseeing the implementation of associated action plans

·  Undertaking monthly reviews of the CSC risk registers, including the monitoring of risks identified through the audits of IP

·  Escalating any issues that, for whatever reason, cannot be resolved to the Risk Assurance Committee for discussion and potential transfer to Trust Risk Register

Infection Prevention (IPT)

The IPT consists of an Associate Director Infection and Patient Safety, a Lead Nurse, an Analyst, single and dual role clinical nurse specialists and practitioners, and Surveillance/Data support staff.

The core functions of the Team fall into the following four domains:

The IPT is responsible for:

·  Providing expert reactive and proactive information and advice to all staff, patient, relatives and carers in respect of healthcare associated infections and the prevention and control of those infections

·  Providing strategic advice to enable to Trust to meet necessary standards of care and fulfill its obligations under the Health and Social Care Act 2008

·  Providing a specialist Vascular Access service for patients through cannulation placement of Peripherally Inserted Central Catheters (PICCs) and Midlines, which includes education and competency assessment of practitioners within the Trust

·  Act as an expect resource for all vascular access i.e., portacaths and hickman lines

·  Providing a comprehensive IP education programme incorporating induction training, annual mandatory refresher training and education tailored to the needs of the Trust.

·  Timely isolation and the enforcement of strict transmission precautions for all enteric and respiratory pathogens

·  The prevention and management of outbreaks resulting from uncontrolled transmission of infection

·  Constantly reviewing the IP education programme to ensure it remains in line with best practice and legislation

·  Ensuring all policies and guidelines are in line with best practice and legislation

·  Contributing to the annual IP plan, in consultation with the IPMC and key stakeholders

·  Contributing to the production of the Annual Report

·  Collating and reporting MRSA and Clostridium Difficile data to the Trust Board, IPMC and to each CSC in accordance with national and local requirements

·  Collating and reporting MSSA and E.coli data to the Trust Board, IPMC and to each CSC in accordance with national and local requirements

·  Providing expert management of infection outbreaks / incidents

·  Advising on aspects of decontamination, including levels of equipment decontamination and cleaning

·  Auditing of IP practices, and from the result of the audit developing priorities for targeted surveillance at local level

·  Advising on the procurement of new equipment in relation IP issues

·  Advising on IP issues prior to commissioning of new buildings and upgrading Trust premises

·  Reviewing, in collaboration with others, the status of the environment and the effectiveness of the facilities management services, including cleaning, in order to provide a safe and clean environment for patient care.

·  Facilitating the identified and trained group of link staff, ensuring they work within defined roles and are empowered to continually raise the standards of IP

·  Conducting root cause analyses of relevant infection incidents

·  Reviewing and responding appropriately to adverse incidents / near misses related to infection prevention and control

·  Working in collaboration with and liaising with Public Health England, Clinical Commissioning Group and GP’s, social services and other local agencies