TRUST DELIVERY GROUP: 22 AUGUST 2017 FOR: APPROVAL DISCUSSION INFORMATION. Acting Chief Nurse & Director of Patient Experience

Transcription

1 TRUST DELIVERY GROUP: 22 AUGUST 2017 FOR: APPROVAL DISCUSSION INFORMATION ITEM Lead: Designation: Jim Murray Acting Chief Nurse & Director of Patient Experience TRUST POLICY AND PROCEDURES FOR ASEPTIC NON-TOUCH TECHNIQUE The Trust Delivery Group is asked to note the following: Purpose of the paper presented: To present the reviewed and updated Trust Policy and Procedures for Aseptic Non-Touch Technique Recommendation: The Trust Delivery Group is asked to approve the updates and amendments made to the Trust Policy and Procedure for Aseptic Non-Touch Technique Time required: 10 minutes Primary PRIDE objective: Right First Time Executive Summary Review and update of the policy last reviewed June Amendments made: Full review of the policy reworded in large part to facilitate greater understanding and ease of reference. Greater clarity on key principles of ANTT to include images of processes and common errors made. Some large pieces of text have been replaced with images to facilitate clarity and ease of reference. Review of key responsibilities in line with role reviews Further information on training and assessment processes, including the roles and responsibilities of the key trainers, supported by updated algorithms for safe practice, training, assessment and compliance. Greater clarity on ANTT audit processes Updated references Appendices updated to include all reviewed forms and algorithms. Equality Impact Risk Assessment Completed? Yes/No (Please explain): Key Risks and number, current scores (if on datix)including BAF

2 Resource Implications( include financial, HR, Governance etc. ) None Prior Discussion: Professional Practice Development Meeting (Educators)

3 Trust Policy and Procedures for Aseptic Non-Touch Technique Reference Number POL-IC/12/10 Version: V3 Status Final Author: Barbara Day Job Title: Lead Nurse Professional Development Version / Amendment History Version Date Author Reason 1 Oct 2010 Karen Hill New Policy 2 Jan 2011 Pam Twine 2.1 July 2014 Pam Twine Reformatted to Trust standard Review and minor amendments Intended Recipients: All Staff Groups 3 July 2017 Barbara Day Review and Update Training and Dissemination: Dissemination via the Trust Intranet To be read in conjunction with: Infection Control Policy, The Royal Marsden Manual for Clinical Nursing Procedures In consultation with and Date: Medical Advisory Committee (MAC) JPAC, Heads of Nursing / Senior Matrons, Community of Practice, ICOG, Education, Training & Development (ETD) EIRA stage One Completed Stage Two Completed Yes N/A Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved Trust Development Group Date of Issue July 2017 Review Date and Frequency July 2020 then every 3 years Contact for Review Lead Nurse Professional Development Trust Policy for Aseptic Non Touch Technique June

4 Executive Lead Signature Cathy Winfield Approving Executive Signature Trust Policy for Aseptic Non Touch Technique June

5 Section Contents 1 Introduction 4 2 Purpose and Outcomes 6 3 Definitions Used 6 4 Key Responsibilities/Duties The Lead Executive / Director of Patient Experience & Chief Nurse Clinical Directors / Clinical Governance Facilitators/Infection Control Leads / Divisional Nursing Director/ Consultants/ Matrons/ Senior Nurses/ Senior Sisters / Charge Nurses 4.3 The Professional Development Advisors and Facilitators (PDA/PDF) Key Trainers Employees Trust Infection Control Committee 7 5 ANTT Training 7 6 ANTT Key Trainers 9 7 ANTT Audit 9 8 Monitoring Compliance and Effectiveness 10 9 References 10 Appendices A Process for Completion of ANTT Assessment 11 B ANTT Practical Competency Assessment Form 12 C Train the Trainer Assessment/Update ANTT 14 D Guidance on ANTT Audit Completion 16 Page 6 Trust Policy for Aseptic Non Touch Technique June

6 Trust Policy and Procedures for Aseptic Non-Touch Technique 1. Introduction Aseptic technique is a fundamental component of health care practice, but the standard to which it is undertaken can be inconsistent. If not undertaken correctly, a poor aseptic technique may be instrumental in causing a healthcare associated infection (HCAI). ANTT is a set of principles that aim to ensure safe and efficient aseptic practices. ANTT principles are founded upon a comprehensive theoretical framework that can be applied to all invasive procedures such as intravenous therapy, wound care, blood cultures, cannula insertion/removal and urinary catheterisation (this is not an exhaustive list). It standardises practice and rationalises the many different techniques currently in use. ANTT does not replace clinical expertise, but should complement practice to ensure the reduction of HCAI's. The core components of the ANTT are: - Key Part Identification & Key Part Protection For asepsis to be maintained key parts must not be touched or touch other nonsterile items or surfaces. Many key parts are already protected by their inner as well as outer packaging and this may be sufficient protection if no preparation is required for that key part. Contact with key parts increases the risk of contamination. Needles are manufactured so that they do not require anchoring at the base to remove sheaths. Flicking or pushing off needles and catheters should be discouraged. Popping items out of packaging increases the risk of contact and reduces control. Compliance and a standardised approach to asepsis are vital to be able to reduce HCAIs across the Trust. Breaches of this policy could result in disciplinary action. Trust Policy for Aseptic Non Touch Technique June

7 Aspects to consider when undertaking an Invasive Procedure Consider: Environment, invasiveness, technical difficulty, number and size of key parts/sites, user competency Consider: Location and timing of procedure relative to other activities in the clinical area Consider: Effective decontamination, use of PPE at appropriate times, factors that may undermine efforts Consider: Selecting an appropriate aseptic field for the invasive procedure being undertaken. Consider: If something has not been touched, it is less likely to have been contaminated. Image from ANTT UK Consider: Links in with all the above steps to support the ANTT approach. Trust Policy for Aseptic Non Touch Technique June

8 2. Purpose and Outcomes All practitioners employed by the Trust, and who undertake ANTT, will understand their responsibility in ensuring that the principles of ANTT are practiced and maintained at all times when undertaking any invasive procedure. 3. Definitions Used Key parts: Asepsis: Non-Touch Technique: Specific parts of the equipment that if contaminated by infectious material increase the risk of infection to the patient. In intravenous therapy for example, key parts are the parts of the equipment that come into direct or indirect contact with the liquid infusion or indwelling device, such as needles, syringe tips, intravenous line connections or exposed central line lumens. Freedom from pathogenic micro organisms A method of carrying out procedures so that the risk of introducing infection is minimised. Key parts should not be touched and they should only come into contact with other key parts. To achieve Non-Touch key parts must remain protected by their packaging or by additional items identified for that purpose. If invasive procedures can not physically be completed without touching key parts, sterile gloves must be worn. 4. Key Responsibilities/Duties 4.1 The Lead Executive Director/Director of Patient Experience and Chief Nurse Will report directly to the Chief Executive and the Board. The Director of Infection Prevention and Control (DIPAC) will oversee local control of infection policies and their implementation, including ANTT practice. Will provide clinical leadership and strategic direction to the Professional Development Unit 4.2 Clinical Directors / Clinical Governance Facilitators/Infection Control Leads / Divisional Nursing Director/ Consultants/ Matrons/ Senior Nurses/ Senior Sisters / Charge Nurses Will provide clinical leadership which instils a culture of ANTT practice across the organisation. Will demonstrate high levels of compliance to ANTT practice Will be a champion for ANTT practice Will support consistent adherence to ANTT practice Will challenge unsafe practice Will use ANTT data on each clinical area to focus improvement work; share data and action plan with ward team. 4.3 The Professional Development Advisors and Facilitators (PDA/PDF) Will provide and disseminate evidence based training and assessment across the organisation to ensure that all staff are aware of ANTT practice relevant to their role Will act as an expert group to provide guidance, interpretation and support on ANTT issues Will be a resource for ANTT practice Will ensure consistent adherence to ANTT practice Will challenge unsafe practice Trust Policy for Aseptic Non Touch Technique June

9 4.4 Key Trainers Will instil a culture of ANTT practice across their clinical area Will demonstrate high levels of compliance to ANTT practice Will undertake assessments as required to maintain compliance within their areas Will challenge unsafe practice 4.5 Employees Employees are responsible and will be held accountable for following the Trust ANTT policy. Will access training, assessment and updates as required Will challenge unsafe practice 4.6 Trust Infection Control Committee Will endorse the ANTT policy Will provide an Annual Infection Control Report to the Board, including ANTT activity Will provide an Annual Infection Control Report to and the Quality Assurance Committee, followed by quarterly update reports, including ANTT activity Will receive Action Plans from each Directorate, in line with the agreed rota, for discussion following ANTT Audits. Audit results are reported to the relevant Infection Control Lead, Matron / Senior Nurse / Senior Sister/ Charge Nurse 5 ANTT Training & Assessment: All staff involved in invasive procedures, will receive instruction and training in ANTT. For new starters to the organisation ANTT Training & Assessment will take place during their induction period. The Trust requires practitioners to undergo mandatory competency re-assessment on a 2-yearly basis. Practitioners are required to achieve competency. If practitioners do not achieve competency on the first attempt, a safe practice algorithm (Appendix A) is in place to support staff to achieve competency. Individuals and managers can monitor their compliance with ANTT via the Training Passport. It is the individuals responsibility that they remain compliant with mandatory training. All practitioners must watch the ANTT video which outlines ANTT principles. This video can only be accessed via the ANTT page on Flo. A copy of the current ANTT assessment can be found in Appendix B. It can also be located on the ANTT page on Flo. Trust Policy for Aseptic Non Touch Technique June

10 Process for ANTT Training, Assessment & Compliance Undertake ANTT training via OneStop or Local Key Trainer/ Divisional PDA/PDF Watch ANTT Video found on Flo Individual is observed and assessed undertaking invasive procedure. This can be simulated Successful Trainer to provide feedback. Ensure training is recorded on OLH Unsuccessful Trainer to provide feedback. Follow algorithm in Appendix A The ANTT video includes information on Sharps Safety in line with Trust policies and procedures. Those who have not undertaken previous ANTT training will receive full guidance. The chosen aseptic procedure is broken down into logical step-by-step components and the practitioner will be guided through the assessment. Practitioners are instructed when to perform effective hand hygiene, how to identify and protect key parts prior to and during the procedure, using a non-touch technique. The individual must be assessed on the clinical practice that presents the highest clinical risk. If the individual is competent to undertake blood cultures they must also be assessed on this. Only PDA s/pdf s/educators can assess individuals in blood cultures; not all Key Trainers can assess this competency in relation to blood culture taking. Those who have been previously assessed will proceed from the video to a formal competency assessment. The practitioner will be asked to demonstrate full ANTT principles for a chosen procedure without prior tuition. This is based on the understanding that ANTT should have been embedded within their practice since their first assessment. Following the assessment, the ANTT assessor will provide feedback and inform them of their success or otherwise. If the practitioner is unsuccessful after the 2 nd attempt, an individual action plan will be agreed to identify and facilitate the identified development needs. At this stage, informal performance management will be instigated. A 3 rd date will be agreed for the practitioner to be competency assessed. If after the 3rd attempt competency is still not Trust Policy for Aseptic Non Touch Technique June

11 achieved then the individual s line manager will commence formal performance management. ANTT training and assessments must only be undertaken by an annotated ANTT Key Trainer. Training content and resources are continually reviewed and updated in line with evidence based practice, for the most up to date resources please refer to the ANTT page on Flo 6 ANTT Key Trainer These individuals must demonstrate that they have the knowledge and skills to assess a range of tasks against the principles of ANTT. As well as the ability to share their knowledge, assess others fairly and equitably and challenge unsafe practice as necessary. In order to become a Key Trainer, the individual will undergo training and simulated assessment delivered by the Professional Development Team. Key trainers are usually registered practitioners; however, non-registered staff may become key trainers. This must be discussed with the Professional Development Unit who may decline any individual s request to become a key trainer if it is not deemed essential to service. Key Trainer assessments are only undertaken by the Professional Development Team and Key Trainers are reassessed and Quality Assured every 2 years. If a Key Trainer fails to attend for their two-yearly update, without mitigating circumstances, they will be removed from Our Learning Hub as a Key Trainer. Any assessments undertaken by the individual after removal will be voided. The individuals assessed will not be deemed competent and will have to re-attend for assessment. A copy of the quality assurance form for Key Trainer assessment can be found in Appendix C. 7 ANTT Audit Practices are audited both monthly and quarterly. Audit is undertaken by key individuals to ensure a robust and valid process. This policy applies to all areas of the Trust where asepsis is required. If audit practice is witnessed that could compromise the safety of the patient or expose the patient to a risk of infection, please notify the practitioner immediately (and respectfully) in order to remove the risk. If it is felt that an individual requires additional training, the matter will be escalated to the individual s line manager and the appropriate PDA/PDF for support and action planning. Additional guidance on ANTT audit completion can be found in Appendix D Trust Policy for Aseptic Non Touch Technique June

12 8 Monitoring Compliance and Effectiveness Compliance is promoted by: ANTT training and assessment, with updates and re-assessments in accordance with the policy. ANTT audit ANTT key trainers Monitoring Requirement: Monitoring Method: Infection control, training records and competencies, incident Analysis. Audit, incident analysis, review of training records held in the Trust Our Learning Hub (OLH) Report Prepared by: Lead Nurse Professional Development Unit Monitoring Report presented to: Infection Control Committee Frequency of Report 4-monthly 9 References ANTT UK (2016) ANTT Approach (accessed 22nd June 2017) Derby Teaching Hospitals NHS Foundation Trust (2014) Capability (Performance & Competence) Ref: HR Derby Teaching Hospitals NHS Foundation Trust (2011) Trust Policy and Procedure for Hand Hygiene Reference No: CL Derby Teaching Hospitals NHS Foundation Trust (2016) Trust Policy and Procedure for Infection Prevention and Control. Ref: CL RM Dougherty, L & Lister, L (2015) Royal Marsden Manual of Clinical Nursing Procedures 9 th edition Chichester: John Wiley & Sons Trust Policy for Aseptic Non Touch Technique June

13 Appendix A Process for Completion of ANTT Assessment Pass Feedback / advice / updates to current practice given. Individual to receive detailed and constructive feedback and to be reassessed. Original or copy of the ANTT Form to be placed in the individuals personnel file Pass Line Manager and Divisional PDA / PDF to be informed Smart action plan to be produced in conjunction with Key Trainer /PDA /PDF. Completed Assessment form to be sent to Our Learning Hub or complete e-form on Flo for inclusion on Trust database ure to do this will result in the individual not being compliant. Pass ANTT competence update is required every two years Reassessment to take place within a two-week time frame Copy of SMART Action Plan & Assessment form to retained in personnel file Line Manager and Divisional PDA / PDF to be informed Contact HR for advice and consider commencing the Capability Policy Trust Policy for Aseptic Non Touch Technique June

14 Appendix B Aseptic Non-Touch Technique (ANTT) Practical Competency Assessment Form Division Ward/Department Full Name (as it appears on payslip) Job Title Date Assessors Name Job Title Please ensure that all details are legible. ure to do so will result in your competency not being recorded and you will be required to re-attend training. Invasive Procedure Being Assessed Staff should be assessed undertaking the highest risk procedure relevant to their clinical role. Infusion Therapy Peripheral Cannulation Phlebotomy Wound Care Blood Culture Injection Urinary Catheterisation Cannula Removal Other (please state) Preparation Zone Yes No N/A Effective hand washing was undertaken initially Preparation took place in an appropriate setting Practitioner adheres to Dress Code and appropriate use of Personal Protective Equipment (PPE) Advise Appropriate aseptic field selected General aseptic field (if selected) was cleaned with 70% isopropyl alcohol wipe and allowed to fully air dry for at least 30 seconds Practitioner identifies key parts to Assessor All key parts remain protected throughout preparation Patient Zone Yes No N/A Hand hygiene undertaken at an appropriate time Positive Patient Identification is undertaken and informed consent sought to continue with procedure Advise Correct glove type selected as part of a risk assessment based on the invasive procedure being undertaken Non-sterile key parts cleaned with an approved wipe and allowed to fully air dry for at least 30 seconds before continuing Practitioner demonstrates effective aseptic field management to maintain key part protection throughout procedure Disposal and Documentation Yes No N/A Equipment disposed of correctly with regards to waste management and the safe handling and direct disposal of sharps Advise Effective hand washing was undertaken on completion of the procedure Documentation completed as required Advise Outcome of Assessment Pass (please refer to the procedure-specific discussion points on reverse of this form) (please outline action plan on reverse of this form) Assessor Signature: Practitioner Signature: Trust Policy for Aseptic Non Touch Technique June

15 Aseptic Non-Touch Technique (ANTT) Practical Competency Assessment Form Action plan or Comments Infusion Therapy: Procedure-Specific Discussion Points (tick as applicable) Cannulation: Decontamination of medication vials with 70% isopropyl alcohol single-use wipe Appropriate blunt fill needle for drawing up Use of closed system for single-dose drug admixture (EcoFlac ) Use of appropriate needlefree access device Flushing with push-pause technique End positive pressure flushing technique Use of pre-filled saline syringe (PosiFlush ) Phlebotomy: Use of evacuated blood collection system (Vacutainer ) Order of draw for blood collection bottles Appropriate skin preparation Importance of not re-palpating vein after skin preparation Disconnection of blood collection bottle before withdrawing needle from patient Direct disposal of needle and needle guard as one single-use unit Blood Culture: DTHFT approved training to obtain Blood Cultures Use of DTHFT specific Blood Culture pack and adherence to procedure outlined on pack Completing blue sticker and putting clearly in patient medical notes Urinary Catheterisation: Appropriate cannula sizing Appropriate skin preparation Importance of not re-palpating vein after skin preparation Use of appropriate needlefree access device Flushing with push-pause technique End positive pressure flushing technique Use of pre-filled saline syringe (PosiFlush ) Wound Care: Use of sterile dressing pack for all wound care Appropriate skin cleansing technique (if indicated) Appropriate wound swabbing Injection: Use of appropriate blunt fill needle for drawing up Appropriate skin preparation undertaken Cannula removal: Remove the cannula at a slow and steady movement, keeping the cannula parallel to the vein Inspect the cannula on removal to ensure it looks intact Apply pressure to the gauze over the cannula insertion site for 2-3 minutes Other: please specify Use of specific sterile urinary catheterisation pack Clinical indication for urinary catheterisation Appropriate urinary catheter sizing Importance of ongoing ANTT for urinary catheter maintenance Procedure for obtaining a catheter specimen of urine Trust Policy for Aseptic Non Touch Technique June

16 Appendix C Train-the-Trainer Assessment/Update ANTT Aseptic Non Touch Technique To be undertaken whilst the ANTT key trainer is assessing a practitioner Key Trainer Details: (please print) Division Department Key Trainer Name (as on payslip) Job Title Date QA Assessor Name Job Title Key Trainer and quality assessor agree the ANTT procedure to be demonstrated by the practitioner is suitable for the quality assessment process (based on the Key Trainers knowledge and experience). I agree that I am ready to be assessed X (Sign) ASSESSOR CRITERIA Yes No Comments. Understanding of Roles & Responsibilities: Can demonstrate an awareness of current Trust guidelines and policies i.e. infection control, hand hygiene, sharps and waste disposal, dress code, Can articulate their involvement in the mandatory training process in respect of targets and compliance. Can explain the purpose of quality assurance. Assessor can provide constructive feedback to the practitioner. Prior to Assessment of the Practitioner by the ANTT Key Trainer: Explains the purpose of the assessment. Explains the format of the assessment. Can assist the practitioner to identify a skill for assessment that is within the practitioner s scope or role. Explains and understands the implications of unsuccessful assessments to the practitioner & clinical area. ANTT Key Trainer ensures the practitioner carries out or, if not observed, discusses the following: Correct use of positive patient identification Undertaking of hand hygiene at required intervals. Adherence to dress code including appropriate personal protective equipment (PPE). Identifies the correct aseptic field and that it is cleaned with a 70% alcohol wipe and allowed to dry for the appropriate time. Key parts are identified to the key trainer. Key parts are protected at all times during preparation. The practitioner wears the correct gloves as part of a risk assessment and that they can identify the correct glove choice i.e. sterile or non-sterile. Key parts are cleaned with a wipe where necessary and allowed to dry for the appropriate time. Key parts are protected during the activity. Correct disposal of equipment including the safe handling and direct disposal of sharps and safer sharps. Trust Policy for Aseptic Non Touch Technique June

17 ANTT Key Trainer Underpinning Knowledge The key trainer can clearly identify the key parts for any given task related to ANTT. The key trainer can identify how key parts should be managed e.g. touching, mishandling, placing on unsuitable surfaces, popping packages etc. The key trainer can identify how key parts should be connected or disconnected e.g. not flicking off needles, use of sharps box to remove needles from the syringe etc. The key trainer can identify how to manage key parts during an emergency / urgent situation. The key trainer can articulate the need for a methodical process which removes / avoids the contamination of key parts. The key trainer can discuss between an acceptable departure from the process and the unacceptable contamination of key parts. The key trainer is able to state how assessments are recorded. Assessor can discuss reassessment options if the practitioner is unsuccessful Comments: Actions required or development opportunities identified I confirm my understanding of my responsibilities in relation to the assessment criteria when undertaking competency assessment of ANTT Key Trainer. (Sign) I confirm that the ANTT Key Trainer has demonstrated sufficient knowledge to assess others ANTT Quality Assessor.. (Sign) Trust Policy for Aseptic Non Touch Technique June

18 Appendix D Guidance on ANTT Audit Completion Areas to be audited are identified by the Infection Control Operations Group (ICOG) Areas are allotted to Professional Development Team, these areas may not be within the PDA/F s usual Division/business unit. Separate staff members (both registered and unregistered, from differing professional groups) that are undertaking an ANTT procedure are audited with the allocated areas. Once identified to the staff member notes are taken and not shared, for example name of the staff member or other identifiable elements. If audit practice is witnessed that could compromise the safety of the patient or expose the patient to a risk of infection, please notify the practitioner immediately (and respectfully) in order to remove the risk. Feedback must be given to the individual. If any concerns have been raised the auditor must hand over to the PDA/PDF for the area who can then follow this up with the Senior Sister/Charge Nurse (this enables action plans to be organised in a timely manner) The Spreadsheet in the shared drive will be updated by the Auditor with notes but this confidential information is not for sharing Audit Tool: Aseptic Non Touch Technique audit Ward/Dept: Directorate Adherence Appropriate Correct Aseptic Field Key Parts Appropriate Key Parts Key Part Correct % to Dress Hand Aseptic Field Cleaned with Proctected Gloves used cleaned with Protection Disposal of Elements Elements Code [appropriate PPE] Hygiene Completed Used 70% alcohol during Preparation Throughout approved wipe, where necessary Throughout Equipment Completed Patient Number Procedure Staff Group Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Total % Complian Number of Staff members observed: 0 Summary report: Total % Compliance (all elements complied with): Areas of non-compliance: Additional information: Action Plan: Completed by: Designation: Date: Key to Type of Procedure IV Venepuncture CVAD Catheter Specimen of Urine Cannulation Wound Care Urinary Catheter Insertion Other Trust Policy for Aseptic Non Touch Technique June