Documentation, composition and organisation of infection control programs and plans in Australian healthcare systems: A pilot study

Transcription

1 Infection, Disease & Health (2016) 21, 51e61 Available online at ScienceDirect ORIGINAL RESEARCH journal homepage: Documentation, composition and organisation of infection control programs and plans in Australian healthcare systems: A pilot study Ramon Z. Shaban a,b, *, Deborough Macbeth a, Nicole Vause c, Geoff Simon b a Infection Control Department, Division of Infectious Diseases and Immunity, Gold Coast Hospital and Health Service, Australia b Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Nathan Campus, 170 Kessles Rd, Nathan, Brisbane Australia c Mount Gambier & Districts Health Service, South East Health Service, Country Health SA Local Health Network, Australia Received 23 March 2016; received in revised form 8 April 2016; accepted 8 April 2016 Available online 9 May 2016 KEYWORDS Infection control; Clinical governance; Organizational decision making; Evidence based practice; Cross infection Abstract Background: Healthcare-associated infections (HAIs) are a significant but preventable threat to the quality and safety of health care. Infection prevention and control programs are central to the systematic prevention and control of HAIs and thus providing safe and quality services. Although essential components of quality healthcare, there is little published research that has examined what programs exist and how they are documented, particularly in Australia. The pilot study examined the documentation, composition and organisation of infection control programs in two Australian health jurisdictions. Methods: Using a crossesectional, observational, and mixed-methods design, the pilot study explored the extent to which infection control programs were systematically and formally documented, the components of the associated programs, and the governance arrangements under which they operate in health jurisdictions from two Australian states. The survey questions elucidate information on the documentation, composition and organisation of the infection control policy and procedural documentation in place to guide clinical practice. Survey participants responded via a 29eelement electronic survey that included the submission of accompanying documentation. Descriptive statistical analyses were performed on the survey data and document and policy analytic methods were applied to the associated documentation. Results: Infection control programs and plans are formally organised and documented in the participating jurisdiction, with strong alignment to prevailing jurisdictional requirements while also meeting relevant national standards. The programs and plans in settings with legislative * Corresponding author. Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Nathan Campus, 170 Kessles Rd, Nathan, Brisbane Qld 4111, Australia. Tel.: þ address: r.shaban@griffith.edu.au (R.Z. Shaban) /ª 2016 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.

2 52 R.Z. Shaban et al. obligations were most integrated in their formal organisation and documentation. The findings of this study and the methodology used therein provide information on a subset of national infection control programs, and provide a basis for exploration of the utility of infection control management plans across all Australian health jurisdictions. Conclusion: More research is need to examine programs and plans in other jurisdictions, and also to focus in-detail on the structure and associatedprocessesofprogramsandplansinaction, including evaluative outcomes of performance therein. ª 2016 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved. Highlights Infection prevention and control programs are central to the systematic prevention and control of HAIs and thus providing safe and quality services. Little is known about the composition and organisation of infection control programs in Australia Infection control programs and plans in the participating organisations were formally organised and documented, with strong alignment to prevailing jurisdictional requirements and relevant national standards. Programs and plans in settings with legislative obligations were most integrated in their formal organisation and documentation. Future research should examine infection control programs and plans in other jurisdictions, together with a detailed exploration of programs and plans in action. Introduction t is well established that healthcare-associated infections (HAIs) are a serious and significant threat to the quality and safety of health care [1,2]. An effective infection prevention and control program is central to the systematic prevention and control of HAIs and thus providing safe and quality services. In the contemporary setting, particularly in formal hospital settings, infection control programs and their components are articulated in an official and formal manner via an infection control management plan (ICMP). An ICMP is defined as an official and systematic clinical governance process that is designed to enable institutions to meet their infection prevention and control obligations, and to ensure the safety and quality of the services provided related to infection prevention and control [3]. ICMPs establish institutional and individual accountability for infection prevention and control. For example, there are mandatory elements for facility accreditation to the Australian Council on Healthcare Standards [4]. The Australian Commission on Safety and Quality in Health Care (ACSQHC) National Safety and Quality Health Service (NSQHS) Standards [5] include Standard 3 e Preventing and Controlling Healthcare Associated Infections, which describes the systems and strategies that are required to prevent infection of patients within the healthcare system, and to manage infections effectively when they occur, in order to minimise the consequences [5]. ICMPs must be sympathetic to practice-specific contexts, and embrace, build and extend on each organisation s strategic plan, and define the scope of an infection prevention program within the boundaries of areas such as client demographics, epidemiology of infection, and restricted resources. Moreover, they should enable organisations to prioritize infection prevention activity in accordance with principles of risk management and develop appropriate professional and program performance measures; thereby demonstrating professional and public accountability of the infection prevention program in terms of cost effectiveness and/or costebenefit. Although a seemingly essential component of a quality management system for healthcare, ICMPs are only a recent enterprise in the Australian context. For example, in 2005, in Queensland, the Public Health Act 2005 (Qld) established a legal duty on healthcare facilities and persons involved with the provision of healthcare services to take reasonable precautions to minimise the risk of infection. In Queensland, healthcare facilities must have an ICMP that identifies the risks of healthcare-associated infection and details the measures to be taken to prevent or minimise the risks [6,7]. The Communicable Diseases and Infection Management Branch 1 of the Queensland Department of Health has made available standards and guidelines for healthcare facilities to develop and implement their ICMPs, in both hospital and extra-hospital settings. These include a template for ICMP for declared health services that is based on the National Safety and Quality Health Service (NSQHS) Standard 3: Preventing and controlling healthcare associated infections [5] and various state-based regulatory requirements as defined in the Act. Previous versions of the 1 The Communicable Diseases and Infection Management Branch has superseded the Centre for Healthcare-Related Infection Surveillance and Prevention (CHRISP). Although the division has been retitled the documents are referred to herein as they were expressed at the time of data collection.

3 Infection control programs and plans: Documentation, composition and organisation 53 current (2015) ICMP template are provided for hospital and non-hospital based settings, with different templates for community-based settings. These hospital and extrahospital ICMP templates are populated by the respective healthcare facility to reflect the specific organisational needs. While undoubtedly all quality healthcare organisations and declared health services have, and operate, infection control programs, there is little available in the public or published domain about what comprises these programs and how they are documented. There is a dearth of published research that has examined how infection control programs are formally organised [1,8], of what they are comprised, how they are documented, and how they operate. The documentation, composition and organisation of infection control programs across Australia s diverse health jurisdictions are largely unknown. The aim of this pilot study was to examine the documentation, composition and organisation of infection control programs in two Australian health jurisdictions. Methods Design and setting The purpose of conducting this as a pilot study was to twofold. First, it was to determine whether the methodology was suitable for evaluating the documentation, composition and organisation of infection control programs in Australian health jurisdictions. Second, it was to gauge the level of interest in the study and its methodology, amongst infection control professionals, within the two jurisdictions. Following a successful pilot, a larger study of the documentation, composition and organisation of infection control programs across all Australian health jurisdictions would be undertaken. Using a crossesectional, observational, and mixedmethods design, the pilot study explored in two Australian health jurisdictions described below: 1. To what extent are infection control programs systematically and formally documented? 2. What is the composition of the infection control plans? 3. Under what governance arrangements do infection control programs operate? The choice of the two pilot jurisdictions was based on: (i) the knowledge and experience of the authors with respect the extent to which infection control programs were formalised via plans, and (ii) the nature of the structure of the health departments in each jurisdiction. In Queensland, participation was requested from two of the 16 health districts, namely Metro South Hospital and Health Service (Brisbane), Gold Coast Hospital and Health Service. In South Australia, Country Health SA is one of five local networks within the state. Data collection and definitions Practitioners in charge of infection control programs from health networks in two Australian states (Queensland and South Australia) were invited to contribute to participate in this study. Data was collected via an on-line survey using Adobe Forms Centralä (Adobe Systems Software Ireland Ltd). The survey questions elucidate information on the documentation, composition and organisation of the infection control policy, as well as procedural documentation in place to guide clinical practice. Survey participants were requested to respond to 29 survey elements, and upload copies of relevant policy and procedural documents. Data analysis Data yielded by the survey responses was analysed descriptively using Microsoft Excelä. Documentation submitted by participants detailing their respective infection control programs, including formal infection control management plans where they existed, policies and procedure, were analysed using document and thematic analysis, following the procedures set out by Silverman [9] and Brown [10]. Ethics consideration and approvals Ethics approval for the study protocol was granted by the host research institution s human research ethics committee (Griffith University) as well as ethics committees from the participating jurisdictions. The study was conducted in accordance with the approved protocol, with no participant complaints or withdrawals. Results Participation in the on-line survey was requested from 35 locations across three hospital and health networks, with a response rate of 80% (n Z 28). The 28 respondents represented a range of service types and sizes ranging from a large metropolitan tertiary hospital to small rural hospitals and community health services. Site response rates by jurisdiction were 92% (n Z 12) for Queensland and 73% (n Z 16) for South Australia, as per Table 1. While twelve Queensland sites agreed to participate, due to the networked nature of the respective health services, these twelve sites were represented by five infection control units. Hence, in the jurisdictional analysis below, a maximum of twelve responses relates to site protocols and activities, while a maximum of five responses relates to individual infection control units or respondents. Cross-jurisdictional analysis Overall, the majority of respondents (63%, n Z 12) have been working in ICP roles for greater than five years, and a further 21% (n Z 4) between three and five years. In Queensland, 80% (n Z 4) reported greater than five years in the role, and in South Australia 57% (n Z 8) the same length of experience. Most sites (96%, n Z 27) were public hospitals. All Queensland site responses covered public health services (n Z 12), while 94% (n Z 15) of South Australian responses reported on public facilities. A mixture of parttime and full-time employment status was reported, with 69% indicating that their role is blend of ICP and other

4 54 R.Z. Shaban et al. Table 1 Survey site respondents. Survey element Queensland South Australia Total respondents Number of survey invitations Number of responses Response rate 92% 73% 80% responsibilities. In Queensland 100% (n Z 5) of respondents are in a full-time ICP role, while in South Australia, 29% (n Z 4) were employed full-time, but with a mix of ICP and other responsibilities; 7% (n Z 1) reported part-time employment with ICP being their main responsibility; and 64% (n Z 9) indicating they were part-time and had a mix of ICP and other responsibilities. The proportion of respondents able to devote themselves solely to the ICP function was 26% (n Z 5, all from Queensland), while the majority (63%, n Z 12, all from South Australia) reported spending less than half of their time on ICP, with other responsibilities cited including chemotherapy, stomal therapy and wound management, aged care, staff management and general nursing duties. Of the respondents most (58%, n Z 11) were responsible for a single hospital site, although one Queensland respondent was involved with a network of 18 health care centres with no hospital. Sixty percent (n Z 3) of Queensland practitioners were responsible for two or three sites, while in South Australia, 71% (n Z 10) were responsible for a single site. Some respondents (26%, n Z 5; Queensland Z 1 of 5, South Australia Z 4 of 14) reported a collocated residential aged care facility, and the same overall proportion indicated involvement with community health services, but with a greater number in Queensland (60%, n Z 3 of 5) than South Australia (14%, n Z 2 of 14). A broad range of non-hospital services were supported by the respondents, as summarised in Table 2. The total hospital bed numbers managed by all respondents ranged from less than 50 (53% n Z 10), to between 851 and 1000 (11%, n Z 2). Queensland participants with hospital responsibilities (n Z 4) reported bed numbers between 250 and 1000, while South Australian respondents (n Z 13) identified bed numbers ranging from less than 25, up to 250. All South Australian respondents (n Z 14) carried sole responsibility for the infection control program, while in Queensland only one respondent (20%) had sole responsibility. Other Queensland units comprised two (20%, n Z 1), three (20%, n Z 1) or greater than five (40%, n Z 2) personnel. In South Australia, 86% (n Z 12) reported 0.3 FTE or less allocated to the role, while in Queensland, sites reported employing one (n Z 1), two (n Z 1), three (n Z 1) or greater than five (n Z 2) FTE in the infection control unit. Over half (58% n Z 11) of respondents, including 80% (n Z 4) from Queensland and 50% (n Z 7) from South Australia, indicated that associated nursing units have a portfolio IC nurse, link nurse, or other embedded staff with ICP responsibilities. Of those who confirmed the existence of such roles, all from South Australia (n Z 7) indicated between one and three external staff involved, while Queensland sites reported 15 (n Z 1), 20 (n Z 1), 35 (n Z 1) or 60 (n Z 1) external personnel involved in the program. The responsibilities and activities undertaken by external staff with ICP roles range from attendance at a 1 hour meeting per month to act as a conduit for information and no other protected time, up to one day per fortnight to perform audits, competency assessments and education. Table 2 Non-hospital service areas supported by participating health service respondents. Non-hospital service area QLD (n Z 5) SA (n Z 14) Total (n Z 19) Aboriginal and Torres Strait Islander health 2 (40%) 2 (11%) Aged Care Home support & Home nursing services 1 (7%) 1 (5%) Alcohol, tobacco, other drugs 2 (40%) 2 (14%) 4 (21%) Breast screening 2 (40%) 2 (11%) Child health 1 (20%) 1 (5%) Child protection 2 (40%) 2 (11%) Chronic disease including diabetes, cardio-vascular, respiratory 4 (80%) 1 (7%) 5 (26%) Community Health 1 (20%) 2 (14%) 3 (16%) Detention facilities 2 (40%) 2 (11%) General practice 1 (7%) 1 (5%) Hospital in the home 4 (80%) 1 (7%) 5 (26%) Mental health 4 (80%) 4 (21%) Oral health 1 (20%) 1 (5%) Palliative care 4 (80%) 1 (7%) 5 (26%) Residential aged care 1 (20%) 9 (64%) 10 (53%) Sexual assault 1 (20%) 1 (7%) 2 (11%) Sexual health 1 (20%) 1 (7%) 2 (11%) Tuberculosis 1 (7%) 1 (5%) Women s health 1 (7%) 1 (5%) Youth health 1 (20%) 1 (5%) Mobile locations for services listed above 1 (20%) 1 (5%) Static locations for services listed above 3 (60%) 2 (14%) 5 (26%) None reported 1 (20%) 2 (14%) 3 (16%)

5 Infection control programs and plans: Documentation, composition and organisation 55 Medical input is a feature of all Queensland (n Z 5) and 43% (n Z 6) of the South Australian ICP units. Specialists including medical microbiologists, infectious disease physicians, and public health physicians provide medical support. In all Queensland cases (n Z 5), the support comes from specialists employed in the same health service or network, while 67% (n Z 6) of South Australian sites that reported medical support obtain input from outside their own service. One rural hospital in South Australia also indicated General Practitioner support for ICP in the Emergency Department. Forty percent (n Z 2) of Queensland and 93% (n Z 13) of South Australian respondents indicated that they had a formal infection control policy separate to infection control management plans, while 80% (n Z 4) and 86% (n Z 12) respectively indicated that combined infection control management plans, procedures and guidelines were in place. Jurisdiction-specific features e Queensland 1. Documentation of infection control programs and policy Five Queensland respondents, representing 12 sites and a community health network, were situated within two of the States 16 Hospital and Health Service (HHS) networks. From these, documentation for the whole HHS was provided for two of the four HHS sites in the form of a single infection control management plan that governed the entire HHS. Participants from the other HHS tendered a whole of service ICMP with sub-plans for different divisions of health areas within the HHS, as outlined in Table Composition of the formal infection control plans All of the infection control programs and management plans in the Queensland jurisdiction were formed and documented in accordance with the (former) CHRISP template based on the NSQHS Standard 3. The ICMP from Site One adopted the standard CHRISP template format and it included evidence of compliance or the mechanisms by which evidence is obtained. The plan for this site included all the hospitals, a correctional facility and oral health facility. As outlined in Table 2, Site Two tendered six formal documents. Document 2(a), the Procedure e Infection Control Guidelines, directs staff to the Australian Guidelines for the Prevention and Control of Healthcare-associated Infection [2] as the guiding policy document, thus deferring to national standards rather local ones. Document 2(b), the Infection Control Management Plan (Introduction), provided local clinical governance arrangements, and details regarding consultation and the various related standards incorporates in the plan. Documents 2(c), 2(d) and 2(e), comprising the whole-facility, mental health and aged care plans, were each expressed in the CHRISP template format, and provided evidence of compliance or described a mechanism by which the evidence was obtained. Document 2(f), the Infection Surveillance Plan, incorporated the following elements: hand hygiene; surgical site infection; Staphylococcus aureus bacteraemia, multi-drug resistant organism including vancomycin-resistant enterococcus, lower uterine segment caesarean section; and blood stream infections. Each provided evidence of compliance or the mechanisms by which evidence was obtained. The ICMP from Site Three and Site Four adopted the standard CHRISP template format for the whole-of-facility, and included evidence of compliance or the mechanisms by which evidence is obtained. While the formal documentation was consistent with the (former) CHRISP template, some modification was evident whereby the plan incorporated NSQHS Standard 3 requirements as detailed in Table 4a. The overwhelmingly majority of elements from NSQHS Standard 3 were detailed in the site ICMPs. Not all policies, procedures and protocols were provided, but where the specific document was missing, the facility was assumed to have addressed the issue appropriately if it was described in the ICMP. There was some evidence of variation in interpretation of the ICMP (and therefore Standard 3) requirements. For example, questions around risk assessment for cleaning and disinfection based on transmission-based precautions, where some responses related to instrument reprocessing, interpreted the infectious agent involved, rather than the double clean requirement associated with multi-resistant and spore-forming organisms. 3. Governance of infection control programs Analysis of the ICMPs and associated documentation revealed that the governance of infection control and the Table 3 Infection control program documentation in the Qld jurisdiction. a Hospital and health service district site Formal documents 1 CHRISP Infection Control Management Plan 2 a) Procedure e Infection Control Guidelines b) CHRISP Infection Control Management Plan (Introduction) c) CHRISP Infection Control Management Plan (Whole of Facility) d) CHRISP Infection Control Management Plan (Mental Health) e) CHRISP Infection Control Management Plan (Aged Care) f) Infection Surveillance Plan 3 CHRISP Infection Control Management Plan 4 CHRISP Infection Control Management Plan a Sites were anonymised in the Qld jurisdiction given the specific analysis conducted based on NSQHS Standard 3.

6 56 R.Z. Shaban et al. Table 4a NSQHS Standard 3 specific components of the ICMPs in the Qld jurisdiction. Standard 3 component Sites One Two Three Four 3.1 e Developing and implementing governance systems for effective infection prevention and control to minimise the risks to patients of healthcare associated infections A risk management approach is taken when implementing policies, procedures and/or protocols standard precautions transmission-based precautions aseptic non-touch technique safe handling and disposal of sharps occupational body fluid exposure environmental cleaning and disinfection antimicrobial prescribing outbreak management Yes Yes No Yes instrument reprocessing Yes No Yes Yes single-use devices Yes Yes No No surveillance and data reporting communicable and notifiable disease reporting Yes Yes Yes No provision of risk assessment guidelines to workforce Yes No Yes No exposure-prone procedures Yes No Yes No Use of policies/procedures/protocols regularly monitored Effectiveness of IC systems is regularly reviewed at the highest level of governance Action is taken to improve effectiveness of IC policies/procedures/protocols. 3.2 Undertaking surveillance of healthcare-associated infections Surveillance systems for HAI are in place HAI surveillance data are regularly monitored by the delegated workforce and/or committees 3.3 Developing & implementing systems & processes for reporting, investigating and analysing HAI & aligning these systems to the organisation s risk management strategy Mechanisms to regularly assess the HAI risks are in place Action is taken to reduce the risk of HAI. 3.4 Undertaking quality improvement activities to reduce HAI through changes to practice Quality improvement activities are implemented to reduce and prevent HAI Compliance with changes in practice are monitored The effectiveness of changes to practice are evaluated. 3.5 Developing, implementing & auditing a hand hygiene program consistent with the current national hand hygiene initiative Workforce compliance with current national hand hygiene guidelines is regularly audited Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organisation Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines. 3.6 Developing, implementing and monitoring a risk-based workforce immunisation program in accordance with the current National Health & Medical Research Council Australian Immunisation guidelines A workforce immunisation program that complies with current national guidelines is in use. 3.7 Promoting collaboration with occupational health and safety programs to decrease the risk of infection or injury to healthcare workers Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are implemented to address:

7 Infection control programs and plans: Documentation, composition and organisation 57 Table 4a (continued) Standard 3 component Sites One Two Three Four communicable disease status Yes No Yes Yes occupational exposure management and prophylaxis work restrictions Yes No Yes Yes personal protective equipment Yes No Yes Yes assessment of risk to healthcare workers for occupational allergies evaluation of new products and procedures. 3.8 Developing and implementing a system for use and management of invasive devices based on the current national guidelines for preventing and controlling infections in healthcare Compliance with the system for the use and management of invasive devices is monitored. 3.9 Implementing protocols for invasive device procedures regularly performed within the organisation Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures with invasive devices Developing and implementing protocols for aseptic non-touch technique The clinical workforce is trained in aseptic non-touch technique Compliance with aseptic non-touch technique is regularly audited Action is taken to increase compliance with the aseptic non-touch technique protocols Implementing systems for using standard precautions and transmission-based precautions Standard precautions and transmission-based precautions consistent with the current national guidelines are in use Compliance with standard precautions is monitored Action is taken to improve compliance with standard precautions Compliance with transmission-based precautions is monitored Action is taken to improve compliance with transmission-based precautions Assessing the need for patient placement based on the risk of infection transmission A risk analysis is undertaken to consider the need for transmission-based precautions including: accommodation based on the mode of transmission Yes No Yes Yes environmental controls through air flow Yes No No Yes transportation within and outside the facility Yes No No Yes cleaning procedures Yes No No Yes equipment requirements Yes No No Yes 3.13 Developing and implementing protocols relating to the admission, receipt and transfer of patients with an infections Mechanisms are in use for checking pre-existing HAI or communicable disease on presentation for care A process for communicating a patient s infectious status is in place whenever responsibility for care is transferred between service providers or facilities Developing, implementing and regularly reviewing the effectiveness of the antimicrobial stewardship system An antimicrobial stewardship program is in place The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage Monitoring of antimicrobial usage and resistance is undertaken Action is taken to improve the effectiveness of antimicrobial stewardship Using risk management principles to implement systems that maintain a clean and hygienic environment for patients and healthcare workers Policies, procedures and/or protocols for environmental cleaning that address the principles of infection prevention and control are implemented including: maintenance of building facilities cleaning resources and services (continued on next page)

8 58 R.Z. Shaban et al. Table 4a (continued) Standard 3 component Sites One Two Three Four risk assessment for cleaning and disinfection based on transmission-based precautions and the infectious agent involved. waste management within the clinical environment. laundry and linen transportation, cleaning and storage Policies, procedures and/or protocols for environmental cleaning are regularly reviewed An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly Reprocessing reusable medical equipment, instruments and devices in accordance with relevant national or international standards and manufacturers instructions Compliance with relevant national or international standards and manufacturer s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices is regularly monitored Implementing systems to enable the identification of patients on whom the reusable medical devices have been used A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place Ensuring workforce who decontaminate reusable medical devices undertake competency-based training in these practices Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices Ensuring consumer-specific information on the management and reduction of healthcare associated infections is available at the point of care Information on the organisation s corporate and clinical infection risks and initiatives implemented to minimise patient infection risks is provided to patients and/or carers Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience. associated programs and plans were formally situated within a constituted infection control committee. The origins of the authority for the ICMPs was the Public Health Act 2005 (Qld) that establishes a legal duty on healthcare facilities and persons involved with the provision of healthcare services to take reasonable precautions to minimise the risk of infection. All the participating sites had documented ICMPs and thus were compliant with the legislation. In addition, authority for the ICMP at the HHS level was enshrined in relevant corporate policy and strategic plans, which were referenced therein. Jurisdiction-specific features e South Australia The South Australian Department of Health and Ageing, known as SA Health, provides the overarching governing body for all South Australian Local Health Networks (LHN). There are five LHNs in SA, including Country Health SA Local Health Network (CHSALHN). CHSALN consists of five rural regions, of which three participated in the study. The participating regions, and their respective sites, are detailed in Table 4b. 1. Documentation of infection control programs One rural region supplied and submitted a documented ICMP for eight health units, however there were no individual health unit ICMPs. Infection control programs in CHSALHN include responsibility for blood and body fluid exposure management and healthcare worker immunisation programs. These two areas of responsibility are allocated to different disciplines within the various local health networks in SA Health. The way in which the infection control programs were documented in CHSALHN was stated to be consistent with NSQHS Standard 3 requirements, but these were not expressed for each criterion and sub criterion in the formal documentation for each of the respective sites (as occurs in Queensland). Gaps that had been identified were accompanied by action plans and evidence of their monitoring at the rural, regional, and corporate level was provided. 2. Composition of the infection control plans and programs The South Australian jurisdictional plans followed a standardised audit schedule, each with associated audit tools and reporting templates, which assisted the health units in this research to identify infection prevention and

9 Infection control programs and plans: Documentation, composition and organisation 59 Table 4b Respondents from the South Australian jurisdiction. Rural region South East Rural Region Riverland, Mallee Coorong Rural Region Barossa, Hills Fleurieu Rural Region Site Mount Gambier & Districts Health Service (Public) Penola War Memorial Hospital (Public) Millicent & District Hospital & Health Service (Public) Bordertown Memorial Hospital (Public) Kingston Soldiers Memorial Hospital (Public) Naracoorte Health Service (Public) Mount Gambier Private Hospital (Private) South East Regional Community Health Service (Public) Strathalbyn and Districts Health Services (Public) Mt. Barker and Districts Health Services (Public) Mount Pleasant Hospital (Public) South Coast District Hospital (Public) Murray Bridge Soldiers Memorial Hospital (Public) Karoonda & Districts Soldiers Memorial Hospital (Public) Pinaroo Soldiers Memorial Hospital (Public) Gumeracha Hospital (Public) control risks. This information is contained in an electronic form on the infection control intranet homepage, known to staff as the CHSALHN Wiki. Research respondents submitted pages of the CHSALHN Wiki containing the infection control manual as evidence for standardised procedures and programs. HAI risks were recorded on the Enterprise Risk Assessor (ERA), a standardised, on-line risk management database mandated by SA Health. Only one completed ERA related to HAI was submitted as evidence. 3. Governance of infection control programs The legislative approaches that drive governance and accountability arrangements are set out in the South Australian Health Care Act (2008) (Part 2-Minister and Chief Executive, Part 5 Hospitals, Part 6 Division 1-South Australian Ambulance Service and the South Australian Mental Health Act 2009 Part 12-Administration). There are no provisions within the South Australian Public Health Act (2011) mandating health services and public health units to have an infection control management plan, or oversight by a formally constituted CHSALHN Infection Prevention and Control Committee. At the time of this research there was a SA Health Healthcare Associated Infection Prevention Strategic Framework [11], which guided local health networks in the governance and prevention of all HAI prevention and control programs. Appendix 1 of the Framework provided a checklist for acute healthcare facilities and Appendix 2 was for the non-acute setting in the development of a HAI Infection Management Plan. The checklist included the following five areas: 1) Governance and accountability, 2) Risk assessment, surveillance and monitoring, 3) Infection prevention procedures, 4) Clinician capacity, and 5) Consumer engagement and communication strategy. The only difference in the non-acute checklist was the inclusion of quality improvement under number 3) in place of infection prevention procedures. This document was revised in December 2015, after the survey period, and is now titled the SA Health Healthcare Associated Infection Prevention Policy Directive. [12] In this document an infection management plan for action by each local health network is mentioned on page seven. No individual health unit supplied this completed checklist as evidence. However, the sites adopted CHSALHN wide (corporate) checklists, and respondents indicated that action plans were tendered to the CHSALHN Infection Prevention and Control Committee. Discussion HAIs, as the leading adverse effect associated with health care, are a serious and significant threat to the quality and safety of health care globally [1,2]. At the heart of high quality, safe, effective and efficient health care lays infection prevention and control. Within healthcare settings, infection control activities, of which there are many, collectively form components of an infection control program. Systematising infection control practices by way of a program is fundamental to the provision of high quality, safe, effective and efficient safe care. The overall aim of this pilot study was to examine the documentation, composition and organisation of infection control programs in two Australian health jurisdictions, as a pilot study, to gauge a sense of the systematisation of the programs therein. The first specific aim of the pilot study was to determine the extent to which infection control programs were systematically and formally documented. This study revealed that, in the jurisdictions examined, there were welldefined, formally documented infection control programs, with some variation in the style and format between the two participating jurisdictions. The second aim of the study was to examine the composition of the infection control plans. The authors found that variation in documentation and process was

10 60 R.Z. Shaban et al. marked by geographical and jurisdictional boundaries. The programs and plans were based on sound principles of epidemiology, demonstrated comprehensive engagement of health care workers and others regarding their role in HAI prevention and control. They detailed effective partnerships that facilitate and support implementation of generic and specific infection prevention and control interventions, and documented various mechanisms and processes to ensure implementation of and compliance with infection prevention and control interventions. Such factors are fundamental to an appropriately staffed and resourced infection control program, particularly given increasing pressures for fiscal efficiency and value for money for the available health funding. Health economicsbased research into infection control is a growing focus of research [13], and there is evidence of sentinel studies [14] with significant implications for practice. The greatest consistency of structure and process in the programs and plans occurred in the jurisdiction with a legislative basis underpinning the existence of plans. Local variation of the plans was evident, with demonstrated clear tailoring and application of the infection control structures and process based on different settings and needs. Ensuring programs adopt a risk-based approach is fundamental to high quality and safe care [2]. The third aim was to examine the governance arrangements under which the infection control programs existed and operated. In this study, infection control programs were formally documented by way of formal plans, were situated within established clinical governance frameworks, exhibited clear emphasis on a riskmanagement framework, and were coupled with appropriate professional and program performance measures. The majority of respondents in charge of programs and plans had more than five years experience, and had other duties in addition to infection control as part of their work responsibilities. There is a lack of comparable data regarding these characteristics, but they are consistent with prevailing standards and guidelines [2], some of which have been in draft for many years [15]. Theprograms and plans examined in this research were supported by a range of medical and other specialists including medical microbiologists, infectious disease physicians, and public health physicians, reflecting the diversity of programs and their operational needs as found in international research [8]. Such characteristics demonstrated a focus and emphasis on the level of professional and public accountability of the infection prevention program within the jurisdictions. This pilot study has a range of limitations. The design using cross-sectional survey methods, facilitated the selfreport of data by participants, and the authenticity and veracity of responses cannot be verified. In addition, the study did not examine the outputs of these programs and plans by way of the rates of HAI at the associated sites, although some macro-measures are publically reported [16]. The results of this study are derived from analysis of survey responses and documents submitted, and no observation or in-field examination of the structure and processes of infection control programs and their plans were conducted. Conclusion There is little Australian-based research in the public or published domain about what comprises infection control programs. The documentation, composition and organisation of infection control programs across Australia s diverse health jurisdictions are largely unknown. The results from this pilot study indicate that, in some jurisdictions, infection control programs are formally organised and documented. A larger study of the documentation, composition and organisation of infection control programs across all Australian health jurisdictions should be undertaken. Future research should examine the national perspective of programs and plans, focus in-detail on the structure and process of programs and plans in action, and include evaluative outcomes of performance therein. Authorship statement All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafted the work or revising it critically for important intellectual content; gave final approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding This study was funded by a competitive research grant awarded by Medtronic Infection Control Scholarship, via Covidien Pty Ltd, a Medtronic Company. The authors extend thanks to Medtronic for their generous support. Provenance and peer review Not commissioned; externally peer reviewed. Declaration of interest Author RS is a President of the Australasian College for Infection Prevention and Control and Senior Editor and member of the Editorial Board of Infection, Disease and Health. Author DM is a member of the Executive Council of the Australasian College for Infection Prevention and Control and a member of the Editorial Board of Infection Disease and Health. Neither RS nor DM had any role to play in the peer review or editorial decision-making of the manuscript whatsoever. There are no other conflicts of interest to declare. References [1] Hansen S, Zingg W, Ahmad R, Kyratsis Y, Behnke M, Schwab F, et al. Organization of infection control in European hospitals. J Hosp Infect 2015;91(4):338e45.

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