Infection Prevention and Control Policy

Transcription

1 Infection Prevention and Control Policy March 2012 Ref: PCD053 (v5) Status: Infection Prevention and Control Policy Policy Reference Number IC017 Status Version 5 Implementation Date September 2007 Current/Last Review Dates September 2008, June 2009, February 2011, March 2012; June 2013 Next Formal Review August 2018 Sponsor Chief Executive Sponsor Signature Author Director of Infection Prevention and Control Where available Trust Intranet, Wards, Infection Prevention and Control Department, Bed Bureau Target audience All Trust Staff Ratification Record Clinical Governance and Risk Committee (PDSG) June 2009 Approval Record Committee Name Chairperson Date Infection Prevention and Control Committee Medical Director Sep 07, Sep 08, June 09, Mar 12; June 13 Quality & Safety Committee Medical Director Sep 07, Oct 08 Consultation Date Infection Prevention and Control Committee Members June 09 Occupational Health June 09 Regulators Requirements NHSLA Clinical care 4.9 Standards for Better Healthcare C4 Health and Social Care Act 2008 Healthcare Associated infections (see references) Document Control / History Version No Reason for change 1 Update and include policy into Infection prevention and control Manual 2 Policy reviewed 3 Implementation of the Health and Social Care Act Slight amendment made to Appendix 3 in Feb Policy reviewed

2 Contents Section Page Document Summary 3 1. Introduction 4 2. Purpose 4 3. Definitions 4 4. Accountabilities and Responsibilities 5 5. Infrastructure 8 6. Assurance Framework 8 7. Infection Prevention and Control Programme 9 8. Core Policies/Protocols 9 9. Infection Prevention and Control Training Patient and Public Involvement Monitoring Legal Framework Equality Impact Assessment Acknowledgements References 13 Appendices Appendix 1 Infection Prevention and Control Reporting Structure Appendix 2 Audit Programme - Core Policies Appendix 3 Infection Prevention and Control work programme (2009) Appendix 4 Infection Prevention and Control Manual Contents List Appendix 5 Patient Information Leaflets Dartford and Gravesham NHS Trust Page 2 of 16

3 Document Summary The Trust recognises that its duty of care includes the requirement to contain and minimise acquisition of hospital acquired infection to patients, visitors, and staff. A hospital acquired infection is an infection that was neither present nor incubating at the time of a patient s admission. This policy and accompanying procedures and guidelines apply to all members of staff employed by the Trust, partners, service provider s agency and bank staff contracted by the Trust. The Infection prevention and control Manual contains a variety of policies, guidelines and procedures outlining infection prevention and control measures to be followed by all staff within Dartford and Gravesham NHS Trust. This policy aims to inform all members of Trust staff about the structure and activities of infection prevention and control within the Trust and to define roles and responsibilities. It also describes how staff members can access infection prevention and control advice. Dartford and Gravesham NHS Trust Page 3 of 16

4 1. Introduction Healthcare Associated infections (HCAIs) encompass any infection by any infectious agent acquired by patients as a consequence of treatment or which is acquired by a healthcare worker in the course of their duties. The Trust must therefore ensure that so far as is reasonably practicable, patients, staff, and other persons are protected against risks of acquiring infection through the provision of appropriate care, in suitable facilities, consistent with good clinical practice. Infection prevention and control must also ensure that patients presenting with infection or who acquire infection during treatment are identified promptly and managed according to good clinical practice for the purpose of treatment and to reduce the risk of transmission. Infection prevention and control is an integral part of an effective risk management programme and as such must be embedded into everyday practice and applied consistently by everyone 2. Purpose This policy applies to all staff employed by Dartford and Gravesham NHS Trust and those working on behalf of the Trust. The aim of the policy is to highlight to the organisation the principles of infection prevention and control and the key objectives that must be met by the Trust to prevent and control HCAIs. Objectives: To have in place and operate effective management systems for the prevention and control of HCAI which are informed by risk assessments and analysis of infection incidents Provide and maintain a clean and appropriate environment which facilitates the prevention and control of HCAI Provide suitable and sufficient information on HCAI to the patient, the public and other service providers when patients move to the care of another healthcare provider Ensure that patients presenting with an infection or who acquire an infection during their care are identified promptly and receive appropriate management and treatment to reduce the risk of transmission. Gain the co-operation of staff, contractors and others involved in the provision of healthcare in preventing and controlling infection Provide or secure adequate isolation facilities Secure adequate access to laboratory support Have and adhere to appropriate policies and protocols for the prevention and control of HCAI Ensure, so far as reasonably practicable, that healthcare workers are free of and are protected from exposure to communicable infections during the course of their work, and that all staff are suitably educated in the prevention and control of HCAI These objectives form the compliance criteria from the Health and Social Care Act Code of Practice for the prevention and control of healthcare associated infections. 3. Definitions HCAI Healthcare associated infection (HCAI) refers to infections that occur as a result of contact with the healthcare system in its widest sense - from care provided in the home, to general practice, nursing home care and care in acute or other hospitals. Dartford and Gravesham NHS Trust Page 4 of 16

5 4. Accountabilities and Responsibilities 4.1 Corporate Responsibility The Trust Board must ensure that the organisation meets full compliance with the Health and Social Care Act 2008 (implemented on the 1 st April 2009). The Trust Board will ensure any new guidance relating to the prevention and control of infection is reviewed and any necessary action taken as a result. 4.2 The Chief Executive and Trust Board will: receive infection prevention and control reports as scheduled in the infection prevention and control assurance framework ensure compliance with the Health and Social Care Act 2008 ensure that appropriate management systems for infection prevention and control are in place embed infection prevention and control as an integral part of Trust culture i.e. something that is expected of all staff who work within the Trust as a matter of clinical governance regard lapses in infection prevention and control practice as a serious clinical issue support education at induction for all staff and as appropriate updates for clinical/non clinical staff 4.3 Director of Infection Prevention and Control (DIPC) will: be responsible for the organisation s Infection Prevention and Control Team (IPCT) oversee local infection prevention and control policies and their implementation; be a full member of the IPCT and to attend regularly its infection prevention and control meetings; report directly to the chief executive or equivalent (not through any other officer) and the board or other senior management committee; have the authority to challenge inappropriate clinical hygiene practice and inappropriate antibiotic prescribing decisions assess the impact of all existing and new policies on HCAI and make recommendations for change be an integral member of the organisation s clinical governance and patient safety teams and structures; and produce an annual report on the state of HCAI in the organisation for which he or she is responsible and release it publicly. lead on the antibiotic prescribing policy 4.4 Microbiologist/Clinician in Infection Prevention and Control will: provide an expert clinical microbiology advisory service to the trust play an active role in the infection prevention and control team and working closely with the DIPC, Infection Prevention and Control Networks and other related groups coordinate incident or outbreak management in conjunction with the DIPC ensure that serious untoward incidents are reported to the Governance department and DIPC be involved in the development of infection prevention and control strategy in conjunction with the DIPC advise members of the IPCT on matters relating to clinical microbiology develop adequate laboratory surveillance support to the activities of the IPCT ensure that microbiology laboratory procedures meet national mandatory surveillance requirements 4.5 Infection Prevention and Control Team (IPCT) will: advise the Trust on current best practice in infection prevention and control Dartford and Gravesham NHS Trust Page 5 of 16

6 develop and review policies/procedures and guidelines relating to infection prevention and control distribute policies to all relevant areas and initiate their implementation by means of support, advice and education advise the Trust on current best practice in planning facilities for new construction and refurbishment work plan and deliver a programme of infection prevention and control education to be included in:- - all induction sessions - all planned education sessions - all opportunities for formal and informal education sessions support the directorates in delivering infection prevention and control audit by developing a system of ward/department specific audits audit results and analysis of trends to be presented to the Infection prevention and control Committee and Trust Board and included in the infection prevention and control annual report provide specialist advice to key committees, groups, departments or individual staff on infection prevention and control provide advice to staff on the care and management of patients with infections/infectious diseases carry out alert organism surveillance providing reports to clinical directorate participate in mandatory national surveillance schemes of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia, Clostridium difficile (C. diff) and post operative wound infections in conjunction with the Consultant in Communicable Disease Control (CCDC) identify, monitor and control outbreaks of infection monitor and support incident report in relation to infection prevention and control issues/incident ensure issues for improvement are integrated into a work plan liaise with the Occupational Health department on matters relating to staff health 4.6 Antibiotic Pharmacist (AP) will: promote the safe, rational and prudent use of anti-infective agents within the Trust, in line with Department of Health objectives work closely with the DIPC, microbiologists, the infection prevention and control team, as well as all other members of the healthcare team, to ensure the safe and rational use of antibiotics be the Pharmacy representative on the Trust Infection prevention and control Committee collect, collate, analyse and monitor data from the clinical input of the antibiotic management team (AMT) ward rounds and feeding back referrals made by pharmacy staff support pharmacy, medical and nursing staff in answering anti-infective queries in relation to specific patients and challenging inappropriate prescribing when appropriate target education and training to pharmacy, medical and nursing staff and patients on anti-infective and conduct pharmacy teaching rounds, focusing on management of infections produce, disseminate and update any local clinical guidelines involving the use of antiinfective agents, to be compliant with Trust standards and available on hospital intranet audit and measure adherence to local anti-infective guidelines and feeding back the results to prescribing staff monitor anti-infective expenditure. Dartford and Gravesham NHS Trust Page 6 of 16

7 4.7 Medical Staff Medical staff are expected to implement the infection prevention and control policies and guidelines of the Trust and in the case of consultants, ensure that these are followed in relation to their patients. Consultant staff have an additional responsibility in ensuring that their junior staff receive adequate training and support the other Trust staff in carrying out practices, in relation to infection prevention and control. Infection prevention and control issues must be discussed as part of appraisal by all staff with clinical responsibilities. 4.8 Directorate Responsibilities Each directorate has a responsibility to actively encourage and monitor compliance with the infection prevention and control policy. senior staff within each directorate must act as role models of good infection prevention and control practice in order to encourage better compliance by example managers will be responsible for taking appropriate action when non compliance occurs each directorate must ensure directorate audits of staff compliance with infection prevention and control policies are undertaken directorate audit findings to be presented at least annually to the Infection prevention and control Committee in summarised form ensure the facilities and equipment for infection prevention and control practice are in place so that staff have convenient access and that regular environmental risk assessments are undertaken ensure that all clinical areas have a nominated infection prevention and control link ensure that all staff have received/attended infection prevention and control training act jointly with bed bureau and site managers to minimise the movement of patients unnecessarily ensure individual risk assessments are undertaken upon admission and reflected throughout the patient s plan of care Infection prevention and control issues must be discussed as part of appraisal by all staff with clinical responsibilities. 4.9 Individual Responsibility timely, effective infection prevention and control practice is the personal responsibility of all individuals involved in the provision of healthcare individuals are required to attend relevant education sessions individuals are required to comply with the policies and guidance on infection prevention and control as detailed in the Infection prevention and control Manual Matrons have personal responsibility and accountability for delivering a safe and clean care environment and that the nurse in charge of any patient area has direct responsibility for ensuring that cleanliness standards are maintained throughout that shift Contracted Service Providers will ensure they are fully aware of the Trust Infection Prevention and Control policies and follow these implicitly in the management of their services act proactively to work within the framework of legislation and guidance to support safe provision of healthcare. ensure all their staff are trained in and comply with Infection Prevention and Control provide assurance of compliance with the policy. Dartford and Gravesham NHS Trust Page 7 of 16

8 5 Infrastructure 5.1 Infection Prevention and Control Team (IPCT) As per Department of Health (DoH) recommendations the Trust s Infection Prevention and Control Team (IPCT) has the primary responsibility for providing advice and expertise in all aspects of Infection Prevention and Control. The IPCT reports to the DIPC and through that person to the Chief Executive on all aspects of surveillance, prevention and control of infection within the Trust. The Infection Prevention and Control Team are led by the Director of Infection Prevention and Control and draws on the expertise of an Assistant Director of Infection Prevention and Control, two Consultant Microbiologists and a Senior Infection Prevention and Control Nurse. The IPCT aim to provide an infection prevention and control advisory service to the Trust, staff, patients and visitors, and provide management and control of outbreaks, carry out training for all members of staff, and be key in the formation, implementation and monitoring of Trust infection prevention and control policies. The IPCT conduct day-to-day activities, both proactive and reactive to maintain effective hospital infection prevention and control. The Trust provides 24-hour / 7day access to a consultant Medical Microbiologist. Urgent out-of-hours advice is provided by the on-call consultant Medical Microbiologist who can be contacted via the Trust switchboard at all times. During normal working hours, advice is available from the IPCT. 6. Assurance Framework 6.1 Committee Structure The Trust maintains effective infection prevention and control arrangements through a fully constituted Infection Prevention and Control Committee (IPCC) which meets quarterly. The IPCC reports to the Trust Board and the Clinical Governance and Risk Committee. (Appendix 1). An Infection Prevention and Control Team representative also attend the following key committees, though this list is not exhaustive: Antimicrobial Stewardship Group Clinical Nurse Board Patient Safety Committee 6.2 Statistics on Incidence, Conditions, Outbreaks and Serious Untoward Incidents The Infection Prevention and Control Team work with Clinical Directorates to collate information related to HCAI and Outbreaks. This information is reported monthly by the DIPC to the Clinical Governance and Risk Committee and the Trust Board. The following Infection Prevention and Control information is included as a minimum in the monthly reports: Number of Serious Untoward Incidents, including actions taken Number of MRSA Bacteraemia Number of Clostridium difficile toxin positive patients Any outbreaks of infection, including actions taken This information is summarised and included in the Infection Prevention and Control mid year and Annual Report, which is presented to the Trust Board. The minutes of the ICC, Health and Safety Committee and Trust Board will reflect the receipt and review of the infection prevention and control programme, DIPC report, Dartford and Gravesham NHS Trust Page 8 of 16

9 directorate/specialist written/verbal reports. The minutes will also detail any actions required with designated individual, time frame and action to be taken. 6.3 Audit Programme The Infection Prevention and Control Team have a comprehensive audit programme that is monitored at the Infection Control Committee. The Infection Prevention and Control Team carry out additional audits in clinical areas, covering the core policies detailed in the Health and Social Care Act 2008 (Appendix 2). Feedback is provided to the Directorate managers. A summary of findings is presented to the Infection Prevention and Control Committee. 6.4 Risk Register Infection Prevention and Control issues identified on the risk register and actions taken will be discussed quarterly at the Infection Prevention and Control Committee. Any high risks identified will be escalated through the committee reporting structure in line with the Trust s Risk Management strategy. 7. Infection Prevention and Control Programme The Infection Prevention and Control programme, managed by the DIPC is an ongoing work programme guiding infection prevention and control activity. The programme sets out objectives for the Trust and IPCT to address healthcare associated infections. It provides details of current and planned policies and initiatives that will support and promote good infection prevention and control. The DIPC provides written reports on progress against the programme to the IPCC, CGRC and the Trust Board in the mid year and annual reports Although the DIPC and the IPCT are the prime advocates for infection prevention and control, the Infection Prevention and Control Programme cannot be effectively implemented without the collaboration and support of all staff working for the Trust. 8. Core Policies / Protocols The Health and Social Care Act 2008 (compliance criteria 8) requires the Trust to have policies and protocols for core elements of infection prevention and control. These are: 1. Standard universal precautions 2. Outbreaks of communicable infection 3. Isolation of patients 4. Safe handling and disposal of sharps 5. Prevention of occupational exposure to blood-borne viruses and post-exposure prophylaxis 6. Closure of wards, departments and premises to new admissions 7. Cleaning and Disinfection 8. Decontamination of reusable medical devices 9. Control of outbreaks and infections associated with specific alert organisms 10. Antimicrobial prescribing 11. MRSA Screening Policy Core policies/protocols 1 11 are available on the Trust intranet, this manual is currently being replaced with a set of stand alone policies and guidelines. Dartford and Gravesham NHS Trust Page 9 of 16

10 Core policies will be reviewed by the IPCT biannually or more frequently in response to new national guidance becoming available. Reviewed policies will be presented to the IPCC for acceptance prior to ratification by the Clinical Governance and Risk Committee and Trust Board. 8.2 Infection Prevention and Control Manual / Policies & Guidelines The infection prevention and control manual and infection prevention and control polices and guidelines are on the Trust Intranet (list of contents - appendix 4) The aims of the policies and guidelines are: to provide practical advice on infection prevention and control issues. to promote a safe environment for patients and staff. to minimise the incidence of healthcare associated infections. to prevent cross-infection. to provide timely information about a range of common and important infectious diseases. to be relevant and easy to use. The policies and guidelines will be reviewed biannually by the Infection prevention and control Team. The Policies and guidelines will be presented to the ICC for acceptance. 9. Infection Prevention and Control Training Training for all Trust staff regarding infection will form part of the Trust s mandatory training package. Training in infection prevention and control will be delivered by members of the infection prevention and control team. The training needs analysis for infection prevention and control is detailed in the Trust training policy. This identifies the elements of infection prevention and control to be delivered and the grades / disciplines of staff to receive such training. Additional training is provided during ward rounds/department visits e.g. disease management, cleaning and decontamination. Ad hoc training provided in support of/to additional education programmes. 10. Patient and Public Involvement The Infection prevention and control leaflet Information for Patients and Visitors gives a Trust Board statement of commitment to support staff in the prevention of infection for the benefit of its patients. The leaflet also gives information to support patients and visitors in what they can do to help prevent infections. Other methods of raising public and patient awareness include: patient information leaflets posters attendance at Local Involvement networks (LINks), Community Engagement Group and other public meetings Trust web page informing the public of the Trusts processes and arrangements for preventing and control of healthcare acquired infections as well as links to the Health Protection Agency website and information to access the Patient Advice and Liaison Services (PALs) for further advice. Hospital Acquired Trajectory data (MRSA and C-diff) is available to the public on the Trust website. Dartford and Gravesham NHS Trust Page 10 of 16

11 11. Monitoring What will be monitored Annual IC Report Annual Programme (Live work plan) How/Method Frequency Lead Reporting to Aggregated annual assurance framework data including MRSA bacteraemia / C diff / outbreaks / SUI / audits / training / facilities Annually DIPC IPCC CGRC Trust Board Review Quarterly IPCT DIPC Modern Matrons IPCC Deficiencies / gaps recommendations and actions IPCC CGRC Trust Board IPCC Trust CEO and Board Implementation of any required change. Required changes in practice will be identified and actioned within a specified timeframe and lessons will be shared. Required changes in practice will be identified and actioned within a specified timeframe and lessons will be shared. Core Policies / High Impact Interventions Rolling Audit Programme (Appendix 3) Please see Appendix 3 IPCT IPCC IPCC CGRC Trust Board Required changes in practice will be identified and actioned within a specified timeframe and lessons will be shared. Training attendance for all groups of staff including non attendees Training attendance database Quarterly and aggregated Annually Training Departmen t CGRC IPCC CGRC IPCC Risk Register Review Quarterly IPCT IPCC CGRC IPCC Required changes in practice will be identified and actioned within a specified timeframe and lessons will be shared. Required changes in practice will be identified and actioned within a specified timeframe and lessons will be shared. 12. Legal framework There are a number of pieces of UK and European legislation and Regulations that are relevant to the effective management of infection related risks both in hospital and the community. They identify the expected behaviour of those responsible for the management of infection prevention and control related issues as well as that of individuals providing health care services to others. Whilst not an exhaustive list, the following are major pieces of legislation and regulation: Department of Health (2002) Getting ahead of the curve: A strategy for combating infectious diseases (including other aspects of health protection). A report by the Chief Medical Officer. London: DH. Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: DH. Department of Health (2004) Towards cleaner hospitals and lower rates of infection: A summary of action. London: DH. Dartford and Gravesham NHS Trust Page 11 of 16

12 Department of Health (2006) Standards for better health. London: DH. Department of Health (2007) Clarification and Policy Summary Decontamination of Re-Usable Medical Devices in the Primary, Secondary and Tertiary Care Sectors. London: DH. Department of Health (2007) Essential steps to safe, clean care: reducing healthcare-associated infections. London: DH. Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. London: DH Department of Health (2008) Clean, safe care: reducing infections and saving lives. London: DH. Department of Health (2008) The Health and Social Care Act 2008: Code of practice for the NHS on the prevention and control of health care associated infections and related guidance, London: DH Department of Health (2008) The NHS in England: The operating framework for 2009/10. London: DH Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to deal with the problem. London: DH. National Patient Safety Agency (2008). Patient Safety Alert: Clean hands save lives. London: NPSA. 13. Equality Impact Assessment All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to set out arrangements to assess and consult on how their policies and functions impact on race equality. This obligation has been increased to include equality and human rights with regard to disability age and gender. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This policy was found to be compliant with this philosophy. 14. Acknowledgements Dartford and Gravesham NHS Trust would like to acknowledge the assistance of Bromley Hospitals NHS Trust in producing this policy. 15. References DH/PHLS(1995) Hospital infection prevention and control: guidance on the control of infection in hospitals. HSG(95)10. London. Department of Health Available at DH ( 2002) Getting ahead of the curve. A strategy for combating infectious diseases (including other aspects of health protection). London: DH, Available at: ONTENT_ID= andchk=092Kh4 DH (2003) Winning ways. Working together to reduce Healthcare Associated Infection in England. Report from the Chief Medical officer. London. DH. Available at < e/publicationspampgbrowsabledocument/fs/en?content_id= andchk=j9gyqw> DH (2004a). Towards cleaner hospitals and lower rates of infection: A summary of action. London: DH. Available at: fection/healthcareacquiredgeneralinformation/fs/en Dartford and Gravesham NHS Trust Page 12 of 16

13 DH (2004b). Competencies for Directors of Infection Prevention and Control. London: DH, Available at: earcolleaguelettersarticle/fs/en?content_id= andchk=z4vwx7 DH (2005). Saving lives: a delivery programme for reducing healthcare associated infection (HCAI) including MRSA. London: DH. Available at: < fection/healthcareacquiredgeneralinformation/savinglivesdeliveryprogramme/fs/en> DH (2006). Essential Steps to Safe, Clean Care: Reducing health care associated infection. London: DH, Available at: < fection/healthcareacquiredgeneralinformation/savinglivesdeliveryprogramme/fs/en> DH (2008) Health and Social Care Act Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance DH (2008) The Health and Social care Act Code of Practice for the NHS on the Prevention and Control of Health Care Associated Infections and related guidance. London DH Available at: < Dartford and Gravesham NHS Trust Page 13 of 16

14 Infection Prevention and Control Policy March 2012 Ref: PCD053 (v5) Status: Infection Prevention and Control Reporting Structure Information Tree Trust Board Report Content DIPC Report trend analysis (MRSA, C. diff) Outbreaks Audit results training records RCA/SUI Policy ratification Report by DIPC Frequency of Report Monthly Quarterly Ad hoc Mid year / annually Monitoring of Report Trust Board Minutes will Reflect the receipt / discussion of the infection prevention and control report Detail any actions required with designated individual, time frame and outcome measure Appendix 1 RESPONSE TO VARIANCE If an outbreak occurs, it is discussed at ad hoc DIPC/ Executive meetings, reported at the daily site management team meetings, and in ad hoc Outbreak meetings. Governance and Risk Committee Infection Prevention and control Committee Infection Prevention and control Team Directorate Managers Wards/ Departments Annual report / mid-year DIPC Report Plus policies for ratification DIPC Report plus policies for ratification Infection prevention and control plan Directorate reports PEAT reports Surveillance Audits RCA/SUI Outbreaks Infection prevention and control plan Infection prevention and control audit RCA / PLACE Surveillance outbreaks Infection prevention and control audits PLACE Outbreaks * DIPC DIPC Directorate representative DIPC Infection prevention and control Team Clinical Directors Directorate Manager Matrons Sisters/ Charge Nurses As for Trust Board Quarterly Quarterly Monthly to Clinical Governance (DIPC) Quarterly to Board Monthly Ad hoc * Clinical Governance Minutes will Reflect the receipt / discussion of the infection prevention and control report Detail any actions required with designated individual, time frame and outcome measure Infection prevention and control Committee minutes will Reflect the receipt of and discussion of all reports Detail any actions required with designated individual, time frame and outcome measure IPCT minutes will Reflect discussion of IC programme Detail any actions required with designated individual, time frame and outcome measure Directorate minutes will Reflect receipt of IC report (IC audits, RCA/SI, etc) Detail any actions required with designated individual, time frame and outcome measure Ward meeting minutes will reflect IC audit results PLACE inspection reports RCA/SI (if appropriate) Detail any actions required with designated individual, time frame and outcome measure It is reflected in the monthly ward reports, quarterly Infection prevention and control reports, and monthly Performance Reports to the Trust Board. The Executive Team monitors HCAI information on a daily basis RCA Root cause analysis of incidents PLACE Patient Lead Assessment of the care environment The Assurance framework will be monitored by the DIPC who will maintain a schedule of reports in order to monitor deficiencies, recommendations, actions required and changes requiring implementation. Where the monitoring has identified deficiencies, there must be evidence that recommendations and action plans have been developed and changes implemented accordingly. The DIPC will make the report schedule available to the Chief Executive and Trust Board upon request should further assurance be required in addition to the reporting outlined above.

15 Infection Prevention and Control Policy June 2009 Ref: PCD053 (v3) Status: Ratified Infection Prevention and Control Policies Appendix 2 Policy Title Isolation Policy for Patients Norovirus /Gastroenteritis Guidelines Policy for the Management of Suspected or Confirmed Tuberculosis (including MDR TB) Management of MRSA (Meticillin Resistant Staphylococcus aureus) Guidelines for the Management of Clostridium difficile Control of Infestations: Scabies, Head Lice, Pubic Lice, Body Lice Varicella Zoster Virus (VZV) Chickenpox and Shingles Management of Viral Haemorrhagic Fever (VHF) Hand Hygiene Guidelines Cleaning/Disinfection Policy Guidelines for the Management of Transmissible Spongiform Encephalopathy (TSE) including Creutzfeldt-Jakob Disease (CJD) Meningococcal Meningitis/Septicaemia Control of Glycopeptide Resistant Enterococci (GRE) Control of Multi-Resistant Gram Negative Bacilli Blood Culture Policy Policy for the Prevention of Infections Associated with Vascular Access Devices Guidelines for the Prevention of Infections Associated with the Insertion and Maintenance of Central Venous Devices Guidelines for the Prevention of Infections Associated with Peripheral Venous Catheters Guidelines for the Use of Faecal Management System Insertion, Management, Removal and Prevention of Associated Infections on all Central Venous Devices Infection Control Policy Dartford and Gravesham NHS Trust Page 15 of 16

16 Infection Prevention and Control Policy June 2009 Ref: PCD053 (v3) Status: Ratified Equality Impact Assessment Tool for this Policy To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval Policy Name: Infection Prevention and Control Policy Name of Assessors: Director of Infection Control Yes/No/Possible 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race No Comments (Positive/Negative) Religion or belief No Disability learning disabilities, No physical disability, sensory impairment and mental health problems Gender No Sexual Orientation No Age No 2. Is there any evidence that some groups No are affected differently? 3. If you have identified potential Na discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance No likely to be negative? 5. If so can the impact be avoided? Na 6. What alternatives are there to achieving No the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? Na If you have identified a potential discriminatory impact of this procedural document, please refer it to the PPI Manager, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the PPI Manager. Please ensure you consider all of the following legislation when producing your policy: Gender Sex Discrimination Act 1975 Equal Pay Act 1970 Equalities Act 2006 Gender Recognition Act 2004 Race Race Relations Act 1976 Race Relations (Amendment) Act 2000 Disability Disability Discrimination Act 1995 and 2005 Age Age Regulations 2006 Sexual orientation Equalities Act 2006 Relevant employment legislation Religion and beliefs Equalities Act 2006 Relevant employment legislation Additional Comments: Dartford and Gravesham NHS Trust Page 16 of 16