Infection Prevention and Control Assurance

Transcription

1 Infection Prevention and Control Assurance Who Should Read This Policy Target Audience All Clinical Staff Version 1.0 November 2015

2 Infection Prevention and Control Assurance Policy Ref. Contents Page 1.0 Introduction Purpose Objectives Process Procedures connected to this Policy Links to Relevant Legislation Links to Relevant National Standards Links to other key policy/s References Roles and Responsibilities for this Policy Training Equality Impact Assessment Data Protection and Freedom of Information Monitoring this policy is working in practice 14 Appendices 1.0 Infection Prevention and Control Assurance and Accountability Arrangements Ward/Departmental Infection Prevention and Control Competency Check List Manual of Infection Prevention and Control Standard Operating Procedures 20 Version 1.0 November

3 Infection Prevention and Control Assurance Policy Explanation of terms used in this policy Bacteraemia - The presence of bacteria in the blood a potentially life threatening infection Clinical staff - Clinical staff work directly with patients providing direct care within in-patient and community service areas Competence (Competency) - The ability of an individual to do a job properly. A competency is a set of defined behaviours that provide a structured guide enabling the identification, evaluation and development of the behaviours in individual employees Health Care Associated Infection (HCAI) - Infections that are acquired as a result of healthcare interventions Outbreak - An outbreak is the occurrence of more cases of disease than normally expected within a specific place or group of people over a given period of time Manual of Infection Prevention and Control Standard Operation Procedures (IPCSOPs) - Are standard procedures to be followed in carrying out a given task, a clear set of instructions to be followed to optimise patient and staff safety Surveillance - A system used to detect infections, common source outbreaks and identify problem areas Version 1.0 November

4 Infection Prevention and Control Assurance Policy 1.0 Introduction To meet the requirements of the National agenda for infection prevention and control all NHS organisations are monitored by the Care Quality Commission with regard to the Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infections and related guidance. The Black Country Partnership NHS Foundation Trust is accountable for the provision and range of infection prevention and control services they provide. This includes the provision of infection prevention and control policies, staff training and surveillance programmes. The Trust Board seeks full compliance against the framework of the Health and Social Care Act and this policy provides an assurance framework. The arrangements in this policy are to encourage and support Clinical Groups in their responsibility for effective infection prevention and control in their clinical area and the patients in their care. The Trust will be measured against the criteria listed within the Code of Practice and if compliance is not found, the Care Quality Commission may issue an Improvement Notice. The policy states the duties of staff and objectives of the Infection Prevention and Control Committee. This gives assurance that the Trust complies with the Health and Social Care Act 2008 and endeavours to ensure the risk of healthcare associated infection is kept as low as possible. The Trust is required to reduce the potential for infection. Therefore it is essential that staff seek advice from the Infection Prevention and Control Team prior to the purchase of new equipment, before new building work occurs or any commissioning of capital developments. Managers need to make contact with the Infection Prevention and Control Team at an early stage in order to ensure compliance with essential standards. The tenets of this policy are that: There is support from the Executive Team for the Infection Prevention and Control (IP&C) Programme Trust wide targets are established within the IP&C programme Infection prevention and control is also a Group responsibility Doctors and Ward Managers take responsibility for Infection Prevention and Control within their area Groups complete the annual infection prevention and control programme to reflect their commitment to prevent infections Groups develop action plans to address any deficits highlighted during the audit process and ensure actions are completed in a timely manner Infection Prevention Champions have protected time for IP&C activities IP&C Team liaise with the Groups regarding action planning that is informed by audit Within the Trust, the Director of Infection Prevention and Control (DIPC) and the Infection Prevention and Control Team have prime responsibility for the day-today management of the infection prevention and control service 2.0 Purpose The aim of the policy is to: Ensure that robust arrangements for the prevention and control of infection are in place within the Trust Version 1.0 November

5 Infection Prevention and Control Assurance Policy Ensure that infection prevention and control is embedded at all levels of the organisation from the Board to the Ward Ensure Standard operating procedures and policies for effective infection prevention and control are in place (See Manual of Infection Control Standard Operating Procedures) 3.0 Objectives To reduce healthcare associated infection by providing the highest possible standards of infection prevention and control management within the limitations of available resources To identify the roles and responsibilities of key personnel involved in the prevention and control of infection To identify the functions of the Infection Prevention and Control Committee In order to achieve these objectives the Trust will publish a Manual of Infection Prevention and Control Standard Operating Procedure (IPCSOP) documents which will provide specific guidance for staff. These IPCSOP documents do not form part of this assurance policy but are listed in Appendix 3 and kept up to date by the infection Prevention and Control Team. Any changes are publicised via the Trust s weekly communications bulletin. This catalogue can be updated without the need for re-approving the policy itself. The lead officer who ensures that these documents are regularly updated is the Director of Infection Prevention and Control; each procedure has a review date identified. 4.0 Process The Manual of Infection Control Standard Operating Procedures are listed in Appendix 3, the Manual defines the processes required for each procedure. 5.0 Procedures connected to this Policy Please see Appendix Links to Relevant Legislation Health and Social Care Act 2008 The Health and Social Care Act 2008 sets out the code of practice for the prevention and control of infections. Good Infection prevention, cleanliness and prudent antimicrobial is essential to ensure that people who use health and social care services receive safe and effective care. Effective prevention of infection and cleanliness must be part of everyday practice and be applied consistently by everyone. Good management and organisational processes are crucial to make sure that high standards of infection prevention and cleanliness are set up and maintained. As the regulator of health and adult social care in England, the Care Quality Commission (CQC) will provide assurance that the care people receive, meets the fundamental standards of quality and safety. This Act outlines what registered providers in England, should do to ensure compliance with registration requirement12 (2) (h) providers must assess the risk of, and prevent, detect and control the spread of, infections, including those that are health care associated. It Version 1.0 November

6 Infection Prevention and Control Assurance Policy also sets out the10 compliance criteria against which registered providers will be judged. 6.1 Links to Relevant National Standards CQC Fundamental Standards- Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent service users from receiving unsafe care and treatment, in order to prevent any avoidable harm or risk of harm. To meet the requirement of this regulation, the provider must take appropriate steps to assure itself that the care and treatment it delivers is safe for all service users. This includes assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated. 6.2 Links to other key policy/s Hand Hygiene Policy The aim of hand hygiene is to prevent the spread of infection via the hands by removing transient organisms, or reducing them to a level where they no longer pose a threat to the next person or surfaces touched. Management of Sharps and Inoculation Incidents Policy The aim of the policy is to ensure that Healthcare Workers, work safely with needles and other sharp devices but if they sustain either a percutaneous or a mucocutaneous exposure to blood/ body fluid, they understand the risk of acquiring a blood borne virus infection and the correct procedure to follow to avoid seroconversion. Control Policy for Pandemic Influenza This policy details the infection prevention and control measures that must be implemented and complied with in the event of a pandemic affecting the Black Country Partnership NHS Foundation Trust s. Seasonal Influenza Policy This policy is intended to provide guidance for all healthcare workers within Black Country Partnership NHS Foundation Trust (BCPFT) regarding influenza: recognition; transmission; care of patients with symptoms; staff self-care and prevention of influenza (including vaccine administration to staff and in-patients). Management of Medical devices policy It is a requirement that all NHS Trusts have in place a comprehensive organisation wide policy on the deployment, monitoring and control of medical devices, as outlined in Managing Medical Devices: Guidance for Healthcare and Social Services Organisations This policy covers the provision for systems and process to ensure that whenever/ wherever a device is used it is: Suitable for its intended purpose Properly understood by the professional and end user Maintained in a safe and reliable condition Version 1.0 November

7 6.3 References Infection Prevention and Control Assurance Policy Clean, Safe care: Reducing Infections and Saving Lives( 2008).Department of Health, London The Health & Social Care Act (2008). Department of Health, London Clinical Negligence Scheme for Trusts (CNST): Mental Health and Learning Disability Management Standards (2006) Saving Lives: A delivery programme to reduce healthcare associated infection including MRSA (2005). Department of Health, London Standards for Better Health (2004). Department of Health, London Winning Ways. Working Together to Reduce Healthcare Associated Infection in England (2003). Department of Health, London Getting Ahead of the Curve: A strategy for combating infectious diseases (2002). Department of Health, London Version 1.0 November

8 Infection Prevention and Control Assurance Policy 7.0 Roles and Responsibilities for this Policy Title Role Responsibilities Chief Executive/ Trust Board Director of Infection Prevention and Control (DIPC) Accountable Responsible - Collective responsibility for infection prevention and control within the Trust - Ensure there are effective arrangements in place to reduce the risk of healthcare associated infection and communicable diseases within the Trust - Meet all statutory requirements - Support the measures to prevent and control the risks of healthcare associated infections - The Board will support the provision of adequate resources to secure effective prevention and control of healthcare associated infections - Ensure that Induction & Mandatory Training programmes include the basic principles of Infection prevention, and that programmes are adequately resourced (Groups are accountable for ensuring all staff involved in the direct and indirect care of patients attend appropriate training sessions) - Receive infection prevention and control annual report outlining an effective audit programme that monitors compliance with key policies/standards - Receive exception reports as/when necessary detailing action taken where there are breaches in infection prevention or control - Ensure appropriate management systems for infection prevention and control - Ensure that staff have access to and adhere to clinical care protocols and infection prevention and control policies/standard operating procedures - Chair the Control Committee & ensure the terms of reference are reviewed annually as agreed - Manage the Control Team within the organisation - Oversee local infection prevention and control guidelines and their implementation - Report directly to the Chief Executive, the Board & Executive Committee/ Quality and Safety Committee every quarter and with exception reports as necessary, having the authority to challenge inappropriate clinical hygiene practice as well as inappropriate antibiotic prescribing decisions - Ensure the board is made aware of any potential threats e.g. new resistant organisms - Assess the impact of all existing and new policies/procedures on healthcare associated infection and make recommendations for change - Oversee the production of the annual report on the state of healthcare associated infection within the organisation and release this publicly - Produce an annual programme for the Control Team, which is discussed and agreed by the Board. Quarterly reviews of this plan to be discussed at the Control Committee (& the board as deemed necessary) - Advise the board regarding resources required to support improvements in infection prevention & control - Support the Infection Prevention and Control team in the development and implementation of infection prevention and control standards - Ensure national guidance is implemented promptly within the organisation and that the Infection Prevention and Control annual work plan is amended as required incorporating new national guidance - The DIPC will be an integral member of the organisation s Business and Performance Committee & Quality and Safety Committee Version 1.0 November

9 Title Role Responsibilities Control Committee Approval and Implementation Infection Prevention and Control Assurance Policy - Commission and approve infection prevention and control policies/procedures and standards for the Trust (See Appendix 1 for Infection prevention and control assurance & accountability arrangements Flow Chart) - Ensure that infection prevention and control policies are implemented to ensure patients are protected from preventable infections - Ensure that infection prevention and control activities maintain a high profile within the organisation by meeting formally on a quarterly basis - Main forum where Service Managers/ Matrons representing each Group formulate and agree an annual programme of activities including the commissioning of infection prevention and control policies/procedures - Include the following items in their agenda: Infection prevention and control risks; reviewing of Environmental Health Officers reports following kitchen inspections and the food service; water management (control of Legionella & Pseudomonas); waste management; hospital cleanliness and summaries of infection prevention and control audit activities - Review summaries of their management when appraised of outbreaks of infection in order to learn from experience - Review projects undertaken throughout the year which impact on the prevention and control of infection for patients, visitors and staff - Report as appropriate, any outbreaks or incidents involving microbiological hazard to the Chief Executive. All major outbreaks must also be reported as Serious Untoward incidents to NHS England, Public Health England and Clinical Commissioning Groups - Assist in the planning and development of services and facilities on issues that are relevant to infection prevention & control - Monitor and advise on specific areas of hygiene and infection prevention throughout the Trust - Report on the incidence and prevalence of alert organisms, novel and infectious diseases to the Chief Executive - Review outbreaks of infection and advise service managers on outbreak control and prevention measures for the future - Ensure that patients, visitors and staff, (including contractors) in the Trust are protected from infection wherever possible - Ensure that infection surveillance systems are in place to provide early warning system and to minimise the risk of infection - Ensure that an appropriate education and training programme is available for all Trust staff (including overseeing education necessary for contracted out services) in infection prevention and control practices - Ensure that information is available for patients, staff & visitors on the arrangements for preventing and controlling healthcare associated infections. Information will be available via the Control homepage on the hospital intranet. In addition the annual report will be made available via the Trust Board meetings (open session) Version 1.0 November

10 Title Role Responsibilities Control Team Infection Prevention and Control Champions Lead and support Support Infection Prevention and Control Assurance Policy - Produce the Trusts Annual Control Programme and present it to the Control Committee for validation - Identify any resources required to deliver the annual infection & prevention control programme - Attend the Control Committee & produce quarterly and annual Control reports summarising infection prevention and control activity in the trust during the reporting period - Plan the annual infection prevention and control audit programme and ensure detailed action plans are provided by the Groups to rectify areas of non-compliance. Results from audit activity will be summarised within quarterly and annual infection prevention and control reports to be discussed at the infection prevention & control committee - Collate surveillance data to monitor Healthcare Associated Infections and advise on action to minimise and reduce risks. This includes reporting on the incidence and prevalence of alert organisms, outbreaks and incidents relating to infection prevention & control - Alert DIPC to any increase of infection or potential threats - Monitor and respond to outbreaks of infection by conveying the outbreak management team - Undertake post infection reviews within 14 days of all MRSA, MSSA, E. coli bacteraemia s and deaths (part 1a of death certificate) associated with Clostridium Difficile and to share the learning from such reviews across the Trust and with the wider health care economy - Liaise with Acute NHS Trusts, Public Health England (Local Unit,) Clinical Commissioning Groups, Environmental Health Department and NHS England as required to notify specific infections - Produce and review infection prevention & control policies and standard operating procedures - Develop a programme, in conjunction with the learning and development team,of education for all trust staff in infection prevention and control procedures and management - Advise on infection prevention and control so that designers, architects, engineers, facilities & estate managers etc., working on new-builds, refurbishments or maintenance projects reduce risks of HCAIs at their inception - Advise on the contracting and monitoring process for clinical services e.g., Occupational Health, laundry, clinical waste disposal, domestic services, estates services and laboratory services - Advise on purchase & decontamination of medical devices and all infection control related products, e.g. sharps bins, wipes, gloves etc. - Promote effective communication with all relevant parties both within the Trust and the wider health care economy - Attend local, regional and national infection prevention and control events as requested to influence local and national policy formation in relation to infection prevention & control - The DIPC, Lead Nurse - Control and the Control Nurse provide a service from 9.00am to 5.00pm Mon Friday from the Trust Head Quarters, Delta House (Cover may be arranged outside of working hours by special arrangement) - Act as a local resource and point of contact for infection prevention and control issues. They have received specific training to undertake this role from the Infection Prevention and Control Team - Champion, monitor and ensure best practice in infection prevention and control in their local workplace - Attend regular update meetings with the Infection Prevention and Control Team and feedback to their clinical team leaders/managers - Actively participate in all required infection prevention and control audit activities and report findings to their manager - Complete action plans for areas of non-compliance and report any areas of non-compliance to their manager for action, if the champion is unable to do so Version 1.0 November

11 Title Role Responsibilities Microbiology Services Lead Nurses/ Clinical Directors/ Service Directors Service Managers and Matrons Advice Operational Operational Infection Prevention and Control Assurance Policy - Provide Microbiology and antibiotic prescribing advice for medical staff through service level agreements with: Sandwell and West Birmingham NHS Trust; Royal Wolverhampton NHS Trust; Dudley Group NHS Foundation Trust and Walsall Healthcare Trust - Provide advice for Trust patient s in-patient services within their geographical area (It should be noted that these contracts are under review and services may change in the near future) - Have designated infection prevention and control responsibilities with identified outcome measures - Responsible for monitoring compliance with the infection prevention and control Policies, associated policies and standard procedures. This responsibility also extends to the evaluation and purchase of equipment and supplies - Identify any resources required to implement the infection prevention & control programmes within their Groups - Nominate representatives to attend the infection prevention & control committee. (These should be senior enough to be able to make decisions on behalf of the Group represented) - Discuss any outbreaks, serious problems or hazards relating to infection prevention and control within the Group and ensure action plans are completed and infection prevention & control is a standing agenda item at Group management boards - Ensure infection prevention & control responsibility & accountability is included in all job descriptions & KSFs - Ensure all clinical staff have annual infection prevention and control competency review as part of the annual appraisal process (Appendix 2) - Ensure that the cleanliness of hospital and healthcare premises are of the highest standards. The expectation for this should be included in the KSF for Matrons. They will liaise with and act on behalf of patients to ensure a cohesive approach is taken which will include housekeeping, facilities management and infection prevention and control - Monitor compliance with the infection prevention & control policies/procedures and associated policies - Ensure Team Leaders release staff to attend infection prevention and control training programmes - Ensure infection prevention & control responsibility & accountability is included all job descriptions & KSFs - Ensure all clinical staff have annual infection prevention and control competency review as part of the annual appraisal process (Appendix 2) Version 1.0 November

12 Title Role Responsibilities Team Leaders/ Ward Managers All Employees Operational Implementation Adherence Infection Prevention and Control Assurance Policy - Ensure that healthcare workers are free from and are protected from exposure to communicable infections during the course of their work - Ensure infection prevention & control responsibility & accountability is included in all job descriptions & KSFs for staff in the team - Monitor compliance with the infection prevention & control Policies/procedures and associated policies - Notify the Control Team promptly when clients with known or suspected infection are admitted and ensure an infection risk assessment & care plan is instigated - Ensure that all staff are up to date with mandatory training for infection prevention and control (including new starters) - Release staff to attend induction and mandatory infection prevention and control training programmes, and inform the infection prevention & control team of any additional specific training requirements relating to infection prevention & control - Release and support infection prevention champions directly involved in the infection prevention and control programme to attend meetings and undertake audits as required - Ensure all new starters are assessed on good hand decontamination techniques & complete the competency checklist (Appendix 2) - Ensure all clinical staff have annual infection prevention and control competency review as part of the annual appraisal process (Appendix 2) - Be aware of infection prevention and control policies & procedures and know how to access them - Know how and when to contact the Control Team - Promptly notify the Control Team of any infection risks - Attend induction and mandatory infection prevention and control training sessions as/when required - All clinical staff must complete the annual infection prevention and control competency review as part of the annual appraisal process as directed by their manager (Appendix 2) - Protect patients from infection by undertaking procedures correctly every time, for every patient, in every healthcare setting - see Appendices 2 and Manual of IPCSOPs Version 1.0 November

13 Infection Prevention and Control Assurance Policy 8.0 Training What aspect(s) of this policy will require staff training? Infection Prevention & Control (including Hand Hygiene & Inoculation Incidents) Infection Prevention & Control Champions acting as a local resource and point of contact for infection prevention and control issues Infection Prevention & Control Educational sessions as per service needs Which staff groups require this training? Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? If no, how will the training be delivered? Who will deliver the training? All Trust staff Yes Learning and Development Team Infection Prevention & Control Champions No, champions will receive specific training and educational sessions in relation to their role and responsibilities Internally Infection Prevention & Control Team All clinical staff No Internally Infection Prevention & Control Team How often will staff require training? On induction and annually thereafter Quarterly As and when required to meet service need Who will ensure and monitor that staff have this training? Workforce Development Group Control Team Service Managers/ Matrons 9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this policy in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext or EqualityImpact.assessment@bcpft.nhs.uk Version 1.0 November

14 Infection Prevention and Control Assurance Policy 10.0 Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s activities in respect of service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies Monitoring this policy is working in practice What key elements will be monitored? (measurable policy objectives) Compliance with Hand Hygiene Compliance with Disposal of Sharps Waste Where described in policy? Manual of IPCSOPs SOP 1 Manual of IPCSOPs SOP1 How will they be monitored? (method + sample size) Inpatient Services Audit Community Services Audit Inpatient Services audit Audit Programme for all other areas Who will undertake this monitoring? Control Team Control Team Control Team Control Team How Frequently? Monthly Quarterly Monthly Annually Group/Committee that will receive and review results Control Committee Control Committee Group/Committee to ensure actions are completed Infection Prevention & Control Committee Infection Prevention & Control Committee Evidence this has happened Detailed in Infection Prevention & Control Team s Quarterly and annual reports and exception reports Detailed in Infection Prevention & Control Team s Quarterly and annual reports and exception reports Version 1.0 November

15 Infection Prevention and Control Assurance Policy What key elements will be monitored? (measurable policy objectives) Compliance with Environmental Cleanliness Compliance with the Annual Infection Prevention and Control Audit Programme In all cases of confirmed HCAI Infection the CCG is notified within 24hrs (of the next working day) by the Infection Prevention & Control Team Where described in policy? Manual of IPCSOPs SOP 1 n/a n/a How will they be monitored? (method + sample size) Matrons audits (In- Patient Units only) All Inpatient Units will be audited Other Clinical Services will submit a Self-Assessment Audit Feedback from Clinical Commissioning Group on receipt of quarterly report Who will undertake this monitoring? Service Matrons Control Team Self-Assessment submitted to Infection Prevention & Control Team Control Team How Frequently? Monthly/ Quarterly Annually Annually Quarterly Group/Committee that will receive and review results Control Committee Control Committee Control Committee Clinical Commissioning Group Group/Committee to ensure actions are completed Infection Prevention & Control Committee Infection Prevention & Control Committee Infection Prevention & Control Committee Infection Prevention & Control Committee Evidence this has happened Detailed in Infection Prevention & Control Team s annual report and exception report Detailed in Infection Prevention & Control Team s annual report and exception report Detailed in Infection Prevention & Control Team s annual report and exception report Detailed in Infection Prevention & Control Team s annual report and exception report Version 1.0 November

16 Infection Prevention and Control Assurance Policy Appendix 1 Infection Prevention and Control Assurance and Accountability Arrangements Trust Board / Chief Executive Officer (Infection Control represented by DIPC) Quality & Safety Committee Board of Directors CEO, DIPC & Exec.Team Control Committee Infection Control Team Group Service Directors (via operational Safety & Quality Group) Infection Prevention Champions across the Groups Team Leaders, Ward &/ Departmental Managers All Trust Employees Dashed line Bold line indicates Quality Assurance compliance route indicates Operational Procedure Accountability & Compliance Version 1.0 November

17 Appendix 2 Ward/Departmental Infection Prevention and Control Competency Check List NAME: BAND: Personal No.: DEPT: DATE: This checklist is to ensure an individual s competence around infection prevention & control, hand hygiene and inoculation incidents. The following is not exhaustive, but outlines the main subject areas to be covered. Any specific infection prevention and control issues relating to the ward or department should be addressed as part of this induction. All clinical staff must have local infection prevention and control induction using this competency checklist within 4 weeks of commencement. This checklist must also be completed annually for all Qualified Nurses, Healthcare Support Workers, Medical Staff, Physiotherapy & Occupational Therapy staff. For all other clinical staff, this must be completed every 3 years. Upon completion a copy of this checklist should be retained in your Personal File by your manager, in your own Personal Development Profile. Standard Requirements Assessor please print 1. To be able to locate the infection prevention and control policies and have knowledge & awareness of the contents 2. To demonstrate knowledge of how to find additional IC information, patient leaflets, outbreak charts etc. Demonstrate to the assessor where the policies are located (Dept. folder & intranet) Be able to discuss the type of information contained in the policy folder Be aware of the Trust s responsibilities in relation to the Health and Social Care Act 2008 Demonstrate to the assessor how to access the Infection prevention and control home page on the Trust s intranet 3. To be able to contact Infection prevention and control Demonstrate knowledge of when / how to contact the Infection prevention and control Nurse / Consultant Microbiologist and be aware of the procedures for out of hours 4. To know how & when to wash/decontaminate hands to minimise the risk of transmission of microorganisms Be able to describe the principles of hand hygiene in the prevention of transmission of infection 5. To know when and how to use the correct Personal Protective Equipment (PPE) (gloves, aprons, masks & goggles) 6. To be able to segregate & dispose of sharps waste correctly in line with the Trusts policies 7. To be able to segregate & dispose of household & clinical waste correctly in line with the Trusts policies Be able to demonstrate the Ayliffe hand washing technique Be able to demonstrate correct use of PPE To be able to describe the principles of using PPE in the prevention of transmission of infection To demonstrate correct sharps & waste disposal in-line with the Trust s Waste Management policy To be able to describe the principles of sharps segregation prior to disposal To demonstrate waste disposal in-line with the Trust s Waste Management policy Assessed as competent Date Version 1.0 November

18 Infection Prevention and Control Assurance Policy Standard Requirements Assessor please print 8. To know what to do following a needle stick / blood contamination or similar injury 9. To be able to segregate used/soiled/infected linen correctly & place ready for collection 10. To be able to decontaminate used equipment correctly between each patient use e.g. BP/TPR equipment, stethoscope, commode, hoist & other manual handling equipment etc. To be able to recognise relevant symbols e.g. single use, sterile etc. 11. To be able to collect & label specimens correctly e.g. blood, urine, sputum, faeces, swabs etc. including safe transportation to the laboratory 12. To be able to care for a patient with a known or suspected infection (see isolation policy) 13. To demonstrate competence in aseptic procedures (use of sterile equipment) to maintain asepsis 14 To be able to decontaminate following blood/body fluid contamination incident 15. To be able to recognise and take appropriate action when an outbreak or cluster of infections is suspected 16. To be able to complete a risk assessment in relation to healthcare associated infections & know how to transfer a patient or receive a patient with a known or suspected infection to another ward / healthcare provider To demonstrate knowledge of the immediate first aid required following a needle stick or similar injury to minimise the risk of acquiring an infection To demonstrate knowledge of reporting systems following a needle stick or similar injury To demonstrate knowledge of the correct linen disposal in-line with the Trust s Laundry policy To describe the three levels of decontamination including being able to provide examples of equipment that needs to be decontaminated at those levels. (Cleaning, disinfection & sterilization) Understand who is responsible for cleaning items used in patient care and how and when is this done. Know how to identify single use items. To describe their role in the maintenance of environmental cleanliness and impact on infection prevention and control To know the procedure for microbiological investigation such as specimen collection for screening and investigation, including safe storage & transportation of specimens Understand the principles of isolation; describe how to safely manage patients with specific alert organisms, for example MRSA, diarrhoea, and influenza. To demonstrate correctly a simple aseptic procedure (e.g. injection, small wound dressing) as described in the Royal Marsden manual of clinical nursing procedures To be able to demonstrate how to deal with blood / body fluid spillage as describe in the blood spillage policy To demonstrate an understanding of what an outbreak is and be able to list immediate action to be taken To be able to correctly complete a patient Infection Risk Assessment and take appropriate action Date assessed as competent Version 1.0 November

19 Infection Prevention and Control Assurance Policy Standard Requirements Assessor please print 17. To understand what the standard precautions are and when they should be applied 18. To be able to understand the modes of transmission of influenza, norovirus and other organisms To describe what the standard precautions are To describe how a specific organism is spread from person to person 19. Cadaver bags when & how to use them To demonstrate knowledge of how to find out when to use a cadaver (body) bag and how to obtain one Comments: Date assessed as competent Signature of line manager: Signature of employee: N.B. A copy to be retained in the employees personal fil Version 1.0 November

20 Infection Prevention and Control Assurance Policy Appendix 3 Manual of Infection Prevention and Control Standard Operating Procedures Contents IPC SOP Topic 1 Standard Infection Prevention and Control Precautions (SICPs): Patient Placement, Hand Hygiene - please see separate policy Respiratory Hygiene and Cough Etiquette Personal Protective Equipment (PPE) Management of Care Equipment Cleaning and Maintenance of the Environment Safe Management of Linen Management of Blood and Body Fluid Spillages Safe Disposal of Waste 2 Transmission Based Precautions used in addition to standard precautions Airborne Precautions Contact Precautions Droplet Precautions 3 Surveillance of Infection and Data Collection Alert Organisms Alert Conditions Mandatory Reporting Surveillance & Data Collection 4 Reporting Incidents of Infection to Public Health England and/or the Local Authority 5 Management and Recognition of Outbreaks of Communicable Infection/Disease Outbreak Recognition Outbreak Management Closure of Wards/Departments due to Infection Re-opening of Wards following an Outbreak Version 1.0 November

21 IPC SOP Infection Prevention and Control Assurance Policy Topic 6 Isolation Care of Patients in Isolation due to Infection or Disease Care of Patients in Isolation due to Infection or Disease Source Isolation - for Patients with a Known/Suspected Infection Protective Isolation - for Immunocompromised/Neutropenic Patients 7 Decontamination (Cleaning, Disinfection and Sterilisation) Cleaning Disinfection Sterilisation 8 Sharps and Blood/Body Fluid Contamination Injury Immediate Actions Principles of Good Practice for the Prevention of Inoculation/splash Injuries First Aid - Procedure for Immediate Management of an Occupational Inoculation / Bite or Splash Injury / Incident 9 A-Z of infections A Quick Reference Guide 10 Aseptic Procedures 11 Cleaning Toys, Games & Play Equipment 12 Procurement, Cleaning, Replacement & Audit of Beds, Mattresses & Pressure Cushions 13 Closure of Bays or Wards due to an Infection Control Issue 14 Undertaking a Patient or Environment Infection Risk Assessment 15 Infection Prevention and Control in the Built Environment Key Principles and Considerations Sources of Infection Common Problems to Avoid Post Project Evaluation Recommendations 16 Sharing Information with other Health and Social Care Providers 17 Preventing Infection in Indwelling Urinary Catheters Key Principles for Preventing Infections Associated with the use of Urethral Catheters Other Considerations 18 Post Infection Review (PIR) Version 1.0 November

22 IPC SOP Infection Prevention and Control Assurance Policy Topic 19 Alert Organisms MRSA (Meticillin Resistant Staphylococcus Aureus) What is MRSA? Routes of Transmission for Staphylococcus Aureus and MRSA Clinical Isolates Initial Screening to Identify MRSA Colonisation Decolonisation/Suppression Regime Caring for Patients with MRSA Colonisation/Infection Outbreaks/Periods of Increased Incidence of MRSA 20 Alert Organisms Clostridium Difficile What is Clostridium Difficile? Routes of Transmission for Clostridium Difficile Key Recommendations Caring for Patients with Clostridium Difficile / Potentially Infectious Diarrhoea Reporting Outbreaks/Periods of Increased Incidence of Clostridium Difficile 21 Alert Organisms Glycopeptide Resistant Enterococci (GRE) and Vancomycin Resistant Enterococci (VRE) What is GRE/VRE? Routes of Transmission for GRE Key Recommendations Treatment and Management Reporting Outbreaks/Periods of Increased Incidence of GRE Version 1.0 November

23 Policy Details Infection Prevention and Control Assurance Policy Title of Policy Unique Identifier for this policy State if policy is New or Revised Infection Prevention and Control Assurance Policy BCPFT-CO1-POL-05 New Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * N/A Control of Infection Executive Director of Nursing, AHPs and Governance Infection Prevention and Control Team Infection Prevention and Control Committee June 2014 Month/year policy approved October 2015 Month/year policy ratified and issued November 2015 Next review date November 2018 Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Key Words for this policy Yes Yes Yes B can be disclosed to patients and the public Hand decontamination, Contamination, Infection, Environmental cleanliness * For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance Review and Amendment History Version Date Details of Change V1.0 Nov 2015 Alignment of policies following TCS and new policy format Version 1.0 November