Northern Ireland Practice and Education Council for Nursing and Midwifery

Transcription

1 Northern Ireland Practice and Education Council for Nursing and Midwifery Health Care Associated Infection : a review of staff training and development needs for infection prevention and control Final Report

2 FOREWORD The Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC), on behalf of the Department of Health Social Services and Public Safety (DHSSPS), are pleased to present this review of the training and development needs of Health and Social Care (HSC) staff in Northern Ireland in relation to infection prevention and control (IPC). The review was requested to establish the current situation and to ensure that HSC Trusts avail of current best practice in their promotion of IPC training among staff, as a means of delivering high quality services in terms of patient and client safety. This document sets out recommendations for best practice in relation to relevant training and development for all staff, the resources required to support this and systems and mechanisms necessary to record training for the purpose of demonstrating compliance with regional standards and targets set by the DHSSPS. The members of the Expert Reference Group (ERG) involved in this review provided NIPEC with the multi-professional and multi-agency expertise required to develop training plans in the midst of extreme pressures within their own organisations: in particular the contingency planning for Pandemic A/H1N1 Flu and increased media attention within the area of IPC and Health Care Associated Infection (HCAI). NIPEC would like to take this opportunity to acknowledge their significant commitment and engagement in supporting the achievement of the objectives of this review. Frances McMurray Chief Executive 1

3 CONTENTS Page Introduction 1 Background 3 Methodology for the review 9 Review of training and development for Infection Prevention and Control 11 Regional Proposals for Infection Prevention and Control Training 19 Discussion 21 Conclusion and recommendations 25 References 27 Bibliography 28 Web-sites Sourced 31 Appendices 32 Appendix One Regulation Quality and Improvement Authority: Summary of unannounced hygiene inspections Appendix Two: Aims and objectives of the review Appendix Three: Membership of the NIPEC Review Team Appendix Four: NIPEC Review Team Terms of Reference Appendix Five: Membership of the Expert Reference Group Appendix Six: Expert Reference Group Terms of Reference Appendix Seven : Proposed Training Programme for non-care and volunteer staff Appendix Eight: Proposed Training Programme for all care staff INTRODUCTION 1.1 Health Care Associated Infection (HCAI) has been an area of concern for a number of years at both a UK and international level. Significant issues have specifically arisen in Northern Ireland in recent years, involving outbreaks of infection with serious consequences for patients, clients and their families. This has required a robust response and on-going action by the Department of Health, Social Services 2

4 and Public Safety (DHSSPS) and local health and social care (HSC) organisations to ensure patients and clients are protected. Of particular note are the recent high profile findings and media attention concerning standards of Infection Prevention and Control (IPC) in the Health and Social Care Trusts in Northern Ireland, arising from the Regulation and Quality Improvement Authority reports (RQIA, 2008; 2009). Another significant element of the prevention and control of infection in the HSC is the understanding and competence of all employees in relation to their responsibility to patients, clients and each other. 1.2 In June 2005, the DHSSPS published Protecting Patients and Staff: A Strategy for Prevention and Control of Healthcare Associated Infections in Northern Ireland 2005/2010 (DHSSPS, 2005). This was followed in March 2006 by a second publication, Changing the Culture: an Action Plan for the Prevention and Control of Health Care Associated Infections in Northern Ireland (DHSSPS, 2006). The DHSSPS has published a new Action Plan- Changing the Culture 2010: Strategic Regional Action Plan for the Prevention and Control of Healthcare Associated Infections in Northern Ireland (DHSSPS, 2010). 1.3 The Action Plan (DHSSPS, 2006) identified a number of activities for HSC Trusts to achieve in relation to development and training of staff for IPC, which are contained in Section 4 (actions 9 15). In addition, the most recent edition Changing the Culture Strategic Regional Action Plan (DHSSPS, 2010) also contains activities relative to training and development of health and social care staff. Objective 1, paragraph 1.8 of the updated Action Plan states: 3

5 By January 2010 the Department will complete a regional review of staff training and development needs for infection prevention and control, including domestic supervisors and quality auditors. This review will form the basis for the development of a regional policy of mandatory training, including competency based assessment. 1.4 The Human Resources Directorate (Education and Training) of the DHSSPS asked NIPEC to conduct the above review on its behalf in relation to the training and development needs of staff in the Health and Social Care (HSC) Trusts in Northern Ireland. It was agreed that NIPEC would conduct this review and report back to the DHSSPS by January

6 BACKGROUND Strategy and Policy Context 2.1 A range of strategy and policy documents have been published here in Northern Ireland, in the other three UK countries and elsewhere to develop and enhance systems and processes to prevent and control infection within healthcare environments. To inform the review, a search of UK websites was undertaken (see bibliography) to identify themes arising relevant to IPC strategy and policy. This also provided information about available training and development programmes to evidence best practice from sources outside Northern Ireland. The IPC policies of the six HSC Trusts in Northern Ireland were also requested and examined. Northern Ireland Context 2.2 The DHSSPS is committed to reducing HCAI and protecting patients, clients and staff. This has been demonstrated through a wide range of measures and the publication of various policy documents. As previously identified, in 2005 the DHSSPS published Protecting Patients and Staff: a Strategy for Prevention and Control of Healthcare Associated Infections in Northern Ireland 2005/2010 (DHSSPS, 2005). This strategy used the DHSSPS Prevention and Control of Infection Controls Assurance Standards, which have since been updated for (DHSSPS, 2009). This was followed by the publication of Changing the Culture: an Action Plan for the Prevention and Control of Health Care Associated Infections in Northern Ireland (DHSSPS, 2006). These policy documents required HSC organisations to implement strategic and organisational arrangements to ensure protection of patients and clients. 2.3 In addition, the DHSSPS Quality Standards for Health and Social Care (DHSSPS, 2006) clearly indicates (criterion (f)) that organisations have a responsibility for ensuring properly maintained systems, policies and procedures are in place, which are subject to regular audit and review, including the area of IPC (pages 13-14). The DHSSPS maintains its focus on IPC through the yearly publication of Priorities for Action document, that includes specific targets for HSC Trusts to meet. 2.4 Similarly, the DHSSPS commissioned the development of a Regional Infection Prevention and Control Manual as recommended in Changing the Culture: an Action Plan for the Prevention and Control of Health Care Associated Infections in 5

7 Northern Ireland (DHSSPS, 2006). It was intended that the Manual would help achieve standardisation in Infection Prevention and Control practices across all health care facilities and would be suitable for adaptation as required to reflect specific local needs. For instance, the Manual provides an evidenced based resource for healthcare workers of all grades and professional groups, and is available for use in all healthcare settings, including hospital, community and primary care as well as the private and voluntary sectors. 2.5 Since the reconfiguration of the HSC Trusts in Northern Ireland in 2007 (as a consequence of the Review of Public Administration) the IPC policies from the former legacy Trusts have been harmonised. The policies developed by the current HSC Trusts reflect the guidance outlined in the Northern Ireland Regional Infection Control Manual (DHSSPS, 2008). All policies demonstrated that Trusts currently have processes and systems in place to prevent and control healthcare associated infection. In addition, all Trusts indicated that, through induction and other training activities, IPC policies are brought to the attention of all staff who have access to them via the intranet, hard copy manuals and through information provided at training sessions. 2.6 The Regulation and Quality Improvement Authority (RQIA) for Northern Ireland, a non-departmental public body, also has a role to play in the reduction of HCAI through assessing and reporting on the availability and quality of health and social care services. Reports from a programme of eighteen unannounced hygiene inspections of hospitals across Northern Ireland between March 2008 and September 2009 provide a snapshot of hygiene and infection control standards (RQIA, 2008; 2009). The inspections included direct observations of areas visited, some observations of clinical practice, staff and patient questioning and a review of key documentation in the wards and departments visited. 2.7 Taken together, the eighteen reports demonstrated evidence of good practice in most hospital wards and clinical areas inspected. However, there was evidence of poor practice in all hospital wards and clinical areas inspected giving rise to serious concern. A summary of the themes arising in relation to the poor practice identified is provided in Appendix One. Detailed action plans have since been forwarded by each HSC Trust to address the issues raised by the RQIA inspectors which will, in the future, form part of the infection prevention/hygiene team's re-audit programme 6

8 to look for evidence of sustained improvement, based on the action plans returned. Further visits by RQIA will also be undertaken in the future to ascertain actions taken to address the recommendations of the inspections. 2.8 Nonetheless, IPC issues continue to challenge the DHSSPS and HSC Trusts to ensure the reduction of HCAI and the protection of patients, clients and staff. The updated version of the Changing the Culture 2010: Strategic Regional Action Plan for the Prevention and Control of Healthcare Associated Infections in Northern Ireland (DHSSPS, 2010) includes additional activities for the DHSSPS and for HSC organisations to take forward to further develop systems and processes relative to IPC. This demonstrates an on-going commitment to enhancing the quality of care provided to patients and clients. Context in the other three UK Countries 2.9 The prevention and control of HCAI impacts on all health and social care providers. As with Northern Ireland, Scotland, Wales and England have also been actively engaged in taking forward a range of IPC measures. Interestingly, each of the four UK countries have adopted marginally different approaches to the prevention and control of infection, although similar themes can be seen in their strategies For instance, the Scottish Government has set up an HAI Task Force to take forward its strategy for dealing with IPC and has published a set of HAI Standards. In addition, in collaboration with NHS Education, Scotland, an Education Model (NES, 2009) has been developed to ensure robust training of healthcare staff It is noteworthy that, in England, the Health and Social Care Act (2008) brought about legislative powers for the newly created Care Quality Commission (CQC, England) and, in particular has published a Code of Practice. Breach of statutory duty will incur a range of penalties from the level of raising the matter with the organisation to correct the issue, resulting in monetary penalties, suspending registration and/or prosecution for offences. It is proposed that monitoring against these standards will come into full effect in England in April This significantly raises the profile of ensuring that standards are maintained and sets out consequences of failure Since September 2007, the National Public Health Service for Wales in collaboration with the Welsh Healthcare-Associated Infections Sub-Group 7

9 (WHAISG) has been developing National Infection Control Policies for use across all healthcare boundaries in Wales. Policy development work is in progress commencing with policies for standard infection control precautions, then progressing to transmission-based precautions. As at October 2009, a number of policies have been developed for healthcare organisations to utilise, with others in progress ( International Context 2.13 It is also worthy of note that the Republic of Ireland (RoI) has recently published national standards for IPC in their document National Standards for the Prevention and Control of Healthcare Associated Infections (HIQA, 2009). The Health Improvement and Quality Authority strongly encourages health care organisations to take full account of the standards in implementing their own measures for preventing and controlling Healthcare Associated Infections. The approach for monitoring includes a self-assessment process by organisations which will eventually support a licensing system for healthcare provider organisations. However, unannounced visits will also be part of the Authority s approach The World Health Organisation (WHO) has an active work programme aimed at reducing HCAI. One major area of work in 2009 is the Save Lives, Clean Your Hands Campaign. This workstream incorporates The My 5 Moments for Hand Hygiene approach, which identified the key moments when health-care workers should perform hand hygiene. In addition the WHO Patient Safety team has provided a suite of tools to support health-care facilities to prepare effective Action Plans to improve hand hygiene, regardless of their starting point. The WHO website provides valuable information regarding IPC ( Themes from UK Strategic Approaches 2.15 As indicated above, similar areas have been identified through analysis of the aforementioned UK strategy and policy documents. Consequently, the strategic approaches of the four countries in the UK to IPC can broadly be outlined within the following seven themes: Systems The need for effective systems to support IPC was identified which included surveillance, epidemiology and reporting mechanisms, audit processes, controls 8

10 assurance frameworks, effective records management and development of supportive IT systems, risk and effective patient flow management. It was recommended that quality markers in relation to IPC were reviewed regularly at Trust Board meetings. Environment The maintenance of clean wards and clinical settings were also an integral component of IPC. This included equipment as well as environmental issues and provision was also made for vehicles used for transportation. Attention was drawn to the fact that managers of environments should minimise risk through appropriate maintenance which was inclusive of strict decontamination procedures. Resources Resources should be managed to provide adequate equipment and personnel to manage IPC issues. This included a review of staffing requirements, in relation to specialist IPC teams, general staffing requirements and skill mix for clinical settings, housekeeping teams and adequate laboratory services. A full team approach was advocated across the four countries, making IPC everyone s responsibility. Policy and Procedure The requirement for evidence-based policy and procedure documents across health care provider organisations was included in all of the four country strategy documents which should be monitored by organisations as to the level of compliance. A range of issues were identified as applicable for policy review, examples include: dress code, waste management, decontamination, risk assessment, management of an outbreak, screening and antimicrobial prescription. Training Reviews of current training programmes were suggested to determine the level of IPC training, both specialist and generic. IPC was recommended as an integral part of all formal programmes across undergraduate, pre-registration, in-service, postregistration and continuing professional development curricula. There was recognition of the requirement for a training needs assessment for all staff which should be linked to annual appraisal, mandatory training and continuing professional development schemes. 9

11 Service Improvement IPC was recommended as a focus for ongoing service improvements, where regular audit against prescribed measurable organisational standards provided action plans for reduction of HCAI rates. The adoption of regional comparators/ key performance indicators was suggested in a number of documents, to be incorporated within a national surveillance programme, and organisational priority setting to enhance improvement methodologies. Patient and Public Involvement It was acknowledged that each organisation should have access to the opinions and experiences of their patients/ clients/ carers. Requirements for this area of work in relation to IPC included raising public awareness, public education programmes and the requirement for feedback mechanisms. Screening One final theme identified within a number of the strategy documents related to screening for infections, for example, prior to or on admission to a clinical care setting. Scotland has undertaken an evaluation the cost effectiveness of relevant screening programmes and has recommended further study in this area. The findings from this evaluation demonstrate that screening had major resource implications for both clinical and laboratory staff, equipment and consumables, isolation facilities (if used) and materials for decolonisation of positive patients. However, the study concluded that this should be set against the very high costs incurred when treating patients who develop infections, as well as the cost to the patient experience. 10

12 METHODOLOGY FOR THE REVIEW Proposal 3.1 NIPEC developed a set of proposals for conducting this review, which were agreed by the DHSSPS Regional HCAI Strategic Steering Group. The aim was to complete a review of HSC Trust staff training and development needs for infection prevention and control. The objectives are presented in Appendix Two. The review commenced in July 2009 with a completion date of December Review Team 3.2 A review team (Appendix Three) was subsequently set up within NIPEC, comprising of the Chief Executive and five Senior Professional Officers. The purpose of this team was to oversee the review and conduct the various elements of the work programme. The Terms of Reference for the NIPEC team are listed at Appendix Four. The NIPEC team worked closely with key stakeholders across the HSC sector at all stages throughout the review. To facilitate this, the Chief Executives of the six HSC Trusts were informed of the review in correspondence from the DHSSPS. 3.3 The NIPEC Team was responsible for the quality of the products of the review, which was evaluated on an on-going basis, evidenced through the audit trail provided by notes of meetings and reports. Expert Reference Group 3.4 From the outset of the work programme, it was agreed that an Expert Reference Group (ERG) would be essential to facilitate sourcing the information required to meet the objectives of the review, and to provide expert guidance. An ERG was set up, which was comprised of individuals from the six HSC Trusts who had a specific remit in relation to IPC or had relevant expertise. In order to keep the ERG to a manageable size, a matrix approach was adopted to ensure membership was drawn from all Trusts and across all relevant areas. The membership and Terms of Reference for the ERG are contained at Appendices Five and Six respectively. A small sub-group of IPC experts was also established to address the specific development needs of IPC specialist practitioners. 3.5 The group met on three occasions between September and December The Terms of Reference were agreed with the ERG members at the first meeting held in 11

13 September The Northern Ireland Ambulance Service (NIAS) were not included in the first workshop. However, NIPEC representatives met separately with personnel who have responsibility for IPC policy and training plans in the first instance to establish issues specific to IPC in relation to the Ambulance Service. Subsequently, NIAS representatives were nominated to attend future ERG workshops. Progress Reporting to DHSSPS 3.6 On-going progress of the review was reported regularly to the DHSSPS through meetings and information communications. A meeting was held with DHSSPS representatives in Mid November It was identified that a separate DHSSPS work programme Cleanliness Matters, was underway, addressing environmental cleanliness issues, including training for domestic staff and quality auditors. The objectives of the review were amended at this point to avoid duplication with this workstream and reference to training and development for domestic supervisors and quality auditors were removed from the initial objectives and work programme. 3.7 The objectives of the review were met within the agreed timeframe. The following sections of the report present the results of the review and analysis of data collected in relation to: The policies for IPC training in HSC Trusts The training plans implemented by HSC Trusts The training programmes developed by the Expert Reference Group 12

14 REVIEW OF TRAINING AND DEVELOPMENT FOR INFECTION PREVENTION AND CONTROL 4.1 It was essential to this review that information was gathered from the six HSC Trusts in Northern Ireland regarding their existing training and development for IPC. Information regarding the training and development policies and procedures was requested and collated from the six HSC Trusts through key IPC contacts (see bibliography). IPC training and development across the HSC Trusts 4.2 The information gathered during this review, indicated that there was a variance in the IPC training programmes/strategies for staff with direct and non direct patient care in particular relating to learning outcomes, content and competencies to be achieved. Two of the six HSC Trusts clearly identified learning outcomes, one of which had developed competency based assessments to workshop scenarios. The remaining Trusts indicated that they were reviewing their training plans with a number specifically mentioning that they planned to include competency based assessments. 4.3 Most of the current IPC training was conducted internally throughout the Trusts sites by the IPC staff. Northern Ireland Ambulance Service s (NIAS) IPC training is organised through the Regional Ambulance Training Centre. One Trust identified that it is the manager s duty on an annual basis to ensure the employee meet s the Knowledge and Skills required for their role. In developing Knowledge and Skills Framework (KSF) outlines, the manager has to set the level to which the employee should be working and thereby meeting the requisite level for their role in relation to Infection Prevention and Control. Induction programmes 4.4 Five of the HSC Trusts were noted to have strategies in place for all newly employed staff (clinical and non-clinical) to attend a corporate induction programme. In the remaining Trust, work is currently in progress to develop a corporate induction programme to include Infection Prevention and Control. The corporate induction programmes that are currently in place consist of either a 20 or 30 minute session (with the exception of one Trust whose programme lasts 1hour) which are classified in relation to: 13

15 IPC Structure and Role Access to IPC guidelines and policies Trust IPC Strategy Hand Hygiene ERG members indicated that a significant period of time could elapse between new staff being appointed and the person attending the corporate induction programme. Where IPC was important in relation to the role of the staff member, line managers were responsible for ensuring the staff members were appropriately prepared. This was considered an area of significant concern in relation to protection of patients and clients. Subsequent IPC training 4.5 Subsequent IPC training was categorised in terms of whether staff were either directly or non-directly involved in patient care. The length of time and frequency of the training was calculated as follows: Direct patient care receives a training session of 2-3 hours every 2 or 3 years Non-direct patient care receives a training session of 1 hour every 2 or 3 years ERG members also indicated that some staff, such as finance officers, who were based in facilities where patient care was not provided, did not require any additional training. 4.6 One Trust specified that they used an external training package from Network Publishing, which is a one off training programme in MRSA procedures covering the principles of infection prevention and control. It was noted that all HSC Trusts submit to the DHSSPS Healthcare Associated Infection Prevention and Control Improvement Plan (or equivalent) and a Trust Delivery Plan specifically designed to meet PfA Targets. 4.7 It should be noted that the Health Care Associated Infection Champions Programme, an E-learning package widely used throughout the UK, was purchased by the DHSSPS for Trusts in Northern Ireland However, some confusion was elicited in relation to the target groups who would be trained using this package. The ERG members indicated that some Trusts were informed that it was for training of all staff with a clinical remit whereas others were 14

16 of the view that, as the title would suggest, it was intended for staff with a specialist IPC remit. Notwithstanding the various interpretations, all ERG members, especially the Trust IPC team members, were unanimous in the opinion that the time required to complete the programme (16-20 hours of learning activity) was in excess of the time that Trusts could release staff and that the programme was not fit for purpose in terms of content and learning methodology. 4.8 IPC training programmes throughout the HSC Trusts generally covered the following topics:- Core (Non Direct Care) Role of IPC Team Chain of infection Standard Infection Control Precautions Hand washing Personal protective equipment Laundry management Clinical waste Safe handling and disposal of sharps Health and Safety Legislation General Cleanliness and Decontamination Personal health Personal hygiene Direct Patient Care Intra Venous Care Catheter Care Asepsis Isolation Management of outbreaks Management of Spillages Management of MRSA, Management of Clostridium difficile Enteral Feeding Specimen Collection Preventing the Risk of Microbial Contamination and Outbreak Control 4.9 To complement the mandatory training programme for nurses and midwives, one Trust has included IPC competencies, based broadly on the 6 standard control measures commonly used in IPC practice. 15

17 The competencies cover the areas of: Hand-washing Protective Clothing Used Linen Spillages Cleaning of Equipment Safe Care & Disposal of Sharps & Waste Additional Measures to assist in the reduction of spread Hand washing was assessed through observation by a line manager or infection control nurse. All other areas were assessed by multiple choice type questions All HSC Trusts had identified separate training programmes to include the potential pandemic of the A/H1N1 Virus. These training programmes concentrate on; definition and symptoms; current update information on diagnosis and treatment; spread of A/H1N1 to include control measures and staff precautions A number of HSC Trusts also have several other IPC Training programmes for example: Infection Control in CSSD Infection Control and Antibiotic prescribing Community Training for Domiciliary Care Workers Residential Home training 4.12 The majority of the HSC Trusts identified a number of other methods to disseminate information to inform and update staff. These would be outside of the formal teaching sessions and these methods included: E-Learning and DVD packages Posters IPC Bulletins Memos and advice notes Directed Reading Infection Control Link Nurse (ICLN) Networks Infection control weeks 16

18 Audit and analysis tools incorporated into training programmes 4.13 The HCAI Analysis Tool from the National Patient Safety Agency (NPSA; 2009) has also been incorporated into some training programmes. This is considered to be a quick, simple action tool used when a patient has confirmed MRSA bacteraemia, C.Difficile or other life threatening infections. It works by using the following three stage action checklist: React Record Respond What were the critical problems? What were the main contributory factors/root causes? What needs to be done HCAI Analysis Tool adapted from the National Patient Safety Agency (2009) 4.14 There are many causes of Health Care Associated Infection (HCAI), but they are most commonly caused by the contaminated hands of healthcare workers, contaminated medical devices, and a failure of staff to comply with local policies, procedures and guidelines. Hand Hygiene Audits are conducted in most of the HSC Trusts some of which are based on the World Alliance for Patient Safety Observational Hand Washing Audits ( These have been incorporated into some local training programmes. IPC training in the Independent Sector 4.15 It had been agreed as part of the work programme to undertake a limited exploration of IPC training in the Independent Sector. A short exploratory meeting was held with representatives from Four Season, a large independent health care provider in Northern Ireland. The limitation of this approach is acknowledged since it does not address the issues concerning small independent healthcare providers Four Seasons has a well developed training plan for IPC. They provide a comprehensive induction and updating programme for staff, which is actively monitored by Nursing Home managers and centrally within the organisation. Each new member of staff attends an induction programme, including IPC training within the first 2 days of appointment. A separate induction programme is provided for non-clinical and clinical staff with all staff members attending an annual update. 17

19 Each Nursing Home has a link person for IPC who has received additional training for their role. Each member of clinical staff also undergoes an annual competency and capability assessment, including IPC, required as part of Nursing Home regulations Four Seasons is also currently participating in a research study being carried out by Queen s University, Belfast School of Pharmacy. The study is investigating the effectiveness of IPC training programmes in the Independent Sector. Teaching of IPC in the undergraduate programmes for HSC professionals 4.18 The teaching of Infection Prevention and Control is implicit within all aspects of the undergraduate programmes for health and social care professionals across the three universities in Northern Ireland. IPC Staff based in the HSC Trusts may have input into this training. The programmes incorporate foundation training in year one of each programme in advance of students having contact with patients and clients. This is then updated during each programme and students are assessed in relation to their competence during the programme. Competence assessment takes place during assessment of practice. Additional assessment of competence in simulated settings may also take place using methodologies such as Observed Structured Clinical Examinations (OSCEs) Various methodologies are used for IPC teaching and learning, which may include e-learning packages. Some students are given a DVD entitled Sharps and Splash Injury which reinforces all the theory taught and includes video clips demonstrating good practice in relation to hand washing and all aspects of infection control. Formal post-registration IPC training provision 4.20 Queen s University, Belfast (QUB) provide two stand alone modules for nurses and midwives that specifically address the issue of infectious disease and its management and prevention, these are: Care and Management of Patients with Infectious Disease Infection Control Nursing Apart from these two specific modules, short courses and stand alone modules are also available through the School of Nursing and Midwifery at QUB and the School of Nursing at the University of Ulster. These contain outcomes that address issues 18

20 around preventing the transmission of pathogenic organisms, infectious disease and viruses The Beeches Management Centre and Nurse Education Development Consortium North and West (NEDC) also provide training for nurses and midwives, which include an Infection Control module and a study day on infection Prevention and Control. All of the clinical modules provided by the NEDC have at least one session relating to infection prevention and control. The study days relating to clinical skills (e.g. venepuncture, cannulation, IV administration of medicines, catheterisation, enteral feeding) also refer to relevant infection prevention and control measures. The Return to Nursing and Midwifery programmes and Overseas Nurses Programmes also have sessions included on current Infection prevention and control practice. Training sessions are also delivered to the Independent sector and to non-registered staff in both the Independent and public sectors It was indicated by the IPC specialist nurses at a meeting to discuss their training needs, that limited training and development activity was available in Northern Ireland to meet their specific needs. A few individuals had accessed education programmes in England or Scotland. It was also acknowledged that the University of Ulster is currently in the process of developing an MSc in IPC, although specific details in relation to this were not secured. It is noteworthy that the HSC IPC teams were unaware of this development and had no involvement in the development of the programme The NIPEC review team were only able to source limited information concerning formal IPC post-registration training for other HSC professional groups. However, informal information from the Northern Ireland Medical and Dental Training Agency (NIMDTA) identified that robust processes are in place to train and record such training for newly qualified doctors as part of their induction process. Compliance with regional standards and targets for IPC development and training 4.24 There has been an on-going focus for some years in relation to ensuring all staff members have appropriate training through mandatory processes, including induction and up-date training for staff. Objective 10 of Changing the Culture: an Action Plan for the Prevention and Control of Health Care Associated Infections in Northern Ireland (DHSSPS 2006) stated: 19

21 Infection prevention and control training is to be mandatory for all staff and must be linked to appraisal, individual performance review and job planning process. This should include a mandatory update component. Trusts should aim to achieve 95% coverage for induction training for new staff by 1 April 2007 and for all existing staff by 1 April Objective IV of this review (see Appendix Two) required an investigation of the levels of compliance within HSC Trusts in relation to this objective. In order to measure this and obtain details of any barriers and/or enablers involved in the process, Trusts were asked to complete a pro forma The findings from analysis of the returns demonstrated the following three key themes: Systems A lack of robust systems was evidenced by HSC Trusts for recording staff attendance at IPC training. Although some Trusts were able to provide compliance levels for domestic staff, they were unable to provide accurate records for other staff, particularly clinical staff. One Trust that produced accurate figures found that the IPC administration team keeping records of staff attendance at IPC training was more reliable than other methods. Reported barriers to accurate recording included duplication of staff attending induction training, due to for example, staff starting different posts in the same year and bank staff working on different sites during the same year. Resources Issues around the capacity and low IPC team staffing levels within HSC Trusts were identified, including the lack of dedicated IPC leads. Other issues centred on difficulties in relation to staff being released to attend induction and up-date training. Training to deliver IPC programmes No particular training was identified for IPC trainers. The results demonstrated that the majority of IPC trainers were nurses with a degree within which they may have completed an education module, although it was unclear what this would have entailed. On the job exposure and gradual introduction into the delivery of sessions was presented as acceptable for IPC team members who were providing training. 20

22 REGIONAL PROPOSALS FOR IPC TRAINING 5.1 As indicated previously, a group of experienced practitioners, an expert reference group (ERG) (Appendix Five) were convened comprising staff groups from a range of health and social care professions representing the six HSC Trusts and other relevant organisations, to assist the NIPEC review team in considering best practice in relation to IPC training in Northern Ireland. Where ERG members were not able to attend workshops, opportunities were provided for engagement through communications. ERG members also facilitated the gathering of information from the HSC Trusts in relation to organisational policies and training plans related to IPC. This informed the work of the ERG and the analysis of Trust IPC training and development activities previously presented in this report. The prime purpose of the workshops was to seek engagement and assistance from colleagues to achieve objective IV of the initiative plan which stated: In collaboration with an Expert Reference Group, recommend best practice in relation to training and development to address core training for all staff, additional training for all staff with a clinical remit, and training for staff with a specialist remit for infection prevention and control. 5.2 Members of the ERG were asked to develop programmes based on what they considered to be best practice in relation to the knowledge and skills required for two staff groups, ensuring alignment with best practice. This was necessary to provide an agreed benchmark against which current HSC Trust activities in relation to training and development for IPC could be measured. During the workshop activities ERG members recommended a subdivision of the group of staff who required additional training for a clinical remit. It was considered that this group should be further sub-divided into two, namely: basic training for staff with a clinical remit and secondary level training for staff with an additional clinical remit, for example pertaining to invasive procedures. The rationale for this recommendation was that there were varying degrees of clinical responsibilities and not all staff would require the same in-depth knowledge. It was decided to adopt this recommendation. 5.3 The ERG members, facilitated by NIPEC officers developed draft proposals for training programmes for the identified groups of staff. The proposals included a 21

23 descriptor of the minimal training requirements for induction and on-going training for IPC. The descriptor included: Intended participants Level of learning activity Length of training activity (in hours) The aim of the learning activity Who should deliver the learning activity Aim and objectives of the learning activity Indicative content Mode of delivery Required updates The finally agreed programmes are attached at Appendices Seven and Eight respectively. ERG members agreed that the length of programmes specified, together with follow-up of knowledge and competence development by line managers and IPC teams should be the minimum requirement to ensure staff had a clear understanding of their individual responsibility for IPC. Preparation for IPC specialist nurses 5.4 It was also agreed that ERG members could opt into a subgroup convened in November 2009 for one meeting with the purpose of defining levels of training needs for IPC specialist practitioners. It was noted at this meeting that there was a lack of a regional approach to this important aspect of training and development to ensure IPC specialists were equipped for their role. This included practitioners at Bands 6 and above. It was agreed that attention to this issue was required and that training programmes should be developed and delivered in Northern Ireland, where possible, for Band 6 and 7 IPC practitioners, to ensure the development of local expertise. It was also agreed that specialist posts at Band 8 and above required knowledge and skill development at Advanced Practice level, rather than being IPC specific. The Infection Control Nurses Association (ICNA) of the UK Infection Prevention Society is updating their Core Competencies for Infection Prevention and Control for IPC practitioners. The current competencies were published in 2004 (ICNA, 2004) taking account of the Knowledge and Skills Framework, which would provide a valuable foundation for the development of local programmes. 22

24 DISCUSSION 6.1 The review of the HSC Trust staff training and development needs for infection prevention and control has identified areas of good practice and those that require some attention. The Trust policies and training plans for IPC have been examined together with seeking data regarding attendance at induction and on-going training activities. In addition, the training programmes have been benchmarked against the proposed regional programmes developed by the Expert Reference Group (ERG) convened by NIPEC, see section 3 and Appendices Seven and Eight. The following presents a number of the key issues that emerged from the review. HSC Trust Training programmes 6.2 Each Trust provided information regarding their training programmes and training plans. As part of the review, the Trust training programmes were evaluated against the proposed regional programme identified at para 6.1 above. It should be noted that the proposed programme will require being set within a more comprehensive training framework, if adopted as the regional approach. 6.3 There was evidence of good practice identified within the training plans across all Trusts. The quality of information provided by the Trusts varied. Some provided training plans that included detail regarding induction and on-going training for different staff groups. The planning associated with the programmes was not always clear. In addition, the individuals involved in the delivery of the programmes may not be indicated nor information provided regarding the evaluation strategy adopted to determine effectiveness. 6.4 It was identified that generally Trusts did not set out their training programmes within a framework that enabled robust evaluation of the planning process, intent, delivery and measures to assess outcomes. For example, some Trusts provided PowerPoint presentations when asked for their detailed programmes others provided more detailed information regarding staff groups, content and, on occasions presentations. It was evident that few Trusts set out an aim for the IPC programme/s or included learning objectives. The programmes included similar core content but not all Trusts included all the content identified by the ERG as necessary for the relevant staff groups. 23

25 6.5 There was variance noted in the length of time given to the delivery of the learning activity and frequency of programmes across the Trusts. It has been recommended by the ERG that all non-clinical staff and volunteers should receive induction training for a minimum of one hour and those who regularly enter a building in which care is provided should receive an update every two years. All care staff are recommended to receive induction training of a minimum of 1.5 hours, with staff with additional responsibilities for invasive procedures should receive an additional one hour programme with both groups receiving an update every two years. 6.6 The training plans provided did not always clearly state the length of training provided to different staff groups or differentiate between corporate induction programmes and specific training for clinical staff. Some corporate induction programme sessions related to IPC could be as short as 20 minutes, others up to one hour. As indicated above, it was also difficult to ascertain the specific additional training beyond corporate induction training provided for staff with a clinical remit. This did not meet the minimum length of training identified as best practice by ERG members. Resources 6.7 IPC programmes were generally provided by the HSC Trust IPC teams. It was noted that the IPC team members were not always specifically trained for their role as trainers. It was also indicated that preparation for this role was met through a variety of means, often not involving development of the knowledge and skills required to develop and deliver training programmes. It appeared that subject expertise was the most important factor, some of which was gained through on-thejob exposure. This could be a contributory factor in the information provided in relation to the structure and implementation of training programmes. 6.8 It was also noted by ERG members that the staffing resources Trusts had at their disposal to deliver the training was limited. This generally involved the IPC teams, which caused significant problems in delivering the training required to meet the training identified in training plans. The ERG was of the view that other staff in the Trusts or even other education providers could be used to provide additional expertise. 24

26 6.9 Another significant factor in relation to achieving Trust Training Plans was release of staff to attend training sessions. It is acknowledged that release of staff for all mandatory and on-going development is always a challenge to Trusts, but given the importance of IPC training to ensure public protection this is an issue that requires urgent attention. The RQIA in their report (RQIA 2008; 2009) demonstrated that some staff reported they had not received IPC training, which is an issue for concern The methodology for training may be an additional contributory factor in enabling staff to access training. Most training was delivered using face to face training sessions, with limited use being made of other formats such as DVD or on-line training packages. There are a wide range of on-line training programmes available. As indicated at para 4.7, the HCAI e-learning champion s package was not endorsed by IPC teams as being the most acceptable e-learning package for local use There is a need to explore other on-line packages to evaluate effectiveness. In England, for example, the Chief Nursing Officer has recommended that a core programme for infection control is undertaken by every member of staff. The programme is provided by the Core Learning Unit, DoH, England, has clinical and non-clinical versions and has been mapped to the Knowledge and Skills Framework This in only one example of a number of readily available on-line training packages, which could be used within a blended approach to learning incorporating on-line learning with face to face learning, thereby maximising scarce resources but also providing personal contact with IPC experts. Other modes of learning could be explored such as the use of hard copy work books for staff less familiar with information technology (IT) or who have limited access to IT resources Hard copy, user friendly, information provided to participants in the training programmes was limited. It is essential that information is provided to programme participants to enable them to follow up on their learning and reinforce the messages. The ERG members also indicated that the on-line DHSSPS Infection Control Manual could not be easily accessed by all staff and did not readily lend itself to hard copy printing. They were also of the view that it was not particularly user friendly. It was considered that the development of a format that could be 25

27 printed as hard copy and easily understood by clinical and non-clinical staff would be helpful. Assessment of Competence 6.13 Apart from one Trust, there was minimal mention of formal competency assessment on completion of training programmes, particularly for staff with a clinical remit. Of significant concern was the lack of link with on-going review of performance of IPC knowledge and skills for clinical staff together with the annual Knowledge and Skills Framework personal development planning and review It should be noted, however, that ERG members were significantly exercised by the intention to include competency assessment of IPC knowledge and skills as a requirement in the development of regional policy on mandatory IPC training, as identified in Changing the Culture 2010: Strategic Regional Action Plan (DHSSPS, 2010). This was recognised as being necessary, but concern was raised regarding the resources required to complete such assessments. It was agreed that assessment of competence for IPC should be incorporated into staff appraisal and on-going assessment of performance and should be more explicitly profiled in annual reviews, especially for clinical staff. Systems to Record Training and Development 6.15 As has been noted in this review, HSC Trusts were not able to robustly demonstrate that they had met the requirements of the Objective 10 of the DHSSPS Changing the Culture Action Plan, , (DHSSPS 2006). The Trusts indicated that they generally have limited systems in place to record training for IPC or, in fact, other mandatory training. Line managers are likely to have local systems in place to monitor training for their staff but it is difficult, if not impossible for all Trusts to demonstrate compliance with regional standards and targets set by the DHSSPS. It is recognised that the Human Resources Management System (HRMS) should have the capability to record training and run reports. An exploration of the difficulties associated with record keeping in relation to IPC training requires to be undertaken to develop solutions. A significant governance issue is the inability of Trusts to demonstrate that they are complying with DHSSPS directives in this regard. 26

28 CONCLUSION and RECOMMENDATIONS 7.1 This review has demonstrated that all HSC Trusts in Northern Ireland have systems and procedures in place for training and development in relation to IPC. Section 5 outlined the current provision of IPC training and development programmes throughout the 6 HSC Trusts in Northern Ireland. There are examples of good practice, but as has been indicated there are areas for consideration and attention to ensure all staff working in HSC Trusts are adequately prepared for their role in minimising the incidence of HCAI and protection of the public. 7.2 The objective of this review was to form the basis for the development of regional policy on mandatory IPC training by the DHSSPS to include competency based assessment (DHSSPS, 2009). The NIPEC review team present the following recommendations for consideration by the DHSSPS in taking this action forward: 1. It is recommended that a Regional Group is convened, including patient and public involvement, to take forward the following: develop a standardised approach to IPC training in Northern Ireland taking the proposals contained in Appendices Seven and Eight into consideration to include induction and subsequent training. determine the training needs of IPC specialist practitioners, taking into account the Infection Prevention Nurses Association Core Competencies for Practitioners in Infection Prevention and Control (IPNA, 2004). investigate and make recommendations for the development of systems to facilitate accurate record keeping of IPC training for staff, which can be readily interrogated. 2. It is recommended that a variety of modes of learning are investigated to make best use of resources available and improve access for staff. A menu of learning approaches should be used and, in particular, make full use of available e-learning training programmes together with face to face training. 3. It is recommended that the DHSSPS mandatory training policy takes into account the resource implications of competency assessment and links this with annual KSF review and on-going assessment of competence. 4. It is recommended that consideration is given to the constitution of IPC training teams in relation to capacity to deliver future recommendations arising from 27

29 DHSSPS mandatory IPC training policy, including appropriate preparation for their role. 5. It is recommended that processes are established to evaluate the effectiveness of IPC training programmes. 28

30 REFERENCES Department of Health (2009) The Health and Social Care Act 2008: Code Of Practice for the NHS on The Prevention and Control of Healthcare Associated Infections and Related Guidance. London, DoH. Department of Health Social Services and Public Safety (2005) Protecting Patients and Staff a Strategy for Prevention Infection and Control of Healthcare Acquired Infections in Northern Ireland. Belfast, DHSSPS. Department of Health Social Services and Public Safety (2006) Changing the Culture: An Action Plan for the Prevention and Control of Healthcare Associated Infections in Northern Ireland, 2006/2009. Belfast, DHSSPS. Department of Health Social Services and Public Safety (2006) The Quality Standards for Health and Social Care: Supporting Good Practice and Governance in the HPSS. Belfast, DHSSPS. Department of Health Social Services and Public Safety (2008) The Northern Ireland Regional Infection and Prevention Control Manual. On-line. Available at Accessed 22 nd December Department of Health Social Services and Public Safety (2010) Changing the Culture 2010: Strategic Regional Action Plan for the Prevention and Control of Healthcare Associated Infections in Northern Ireland. Belfast, DHSSPS. NHS Core Learning Unit (2009) Infection Control Programme. On-line. Available at Accessed 22 nd December 2009 Health Information and Quality Authority (2009) National Standards for the Prevention and Control of Healthcare Associated Infections. Dublin: HIQA. NHS Education for Scotland (2009) Healthcare Associated Infection. On-line. Available at Accessed 22 nd December 2009 Infection Prevention Nurses Association (2004) Core Competencies for Practitioners in Infection Prevention and Control. On-line. Available at Accessed 14th December 2009 NPSA (National Patient Safety Agency) (2009) HCAI Analysis Tool. On-line. Available at Accessed 22 nd December Regulation and Quality Improvement Authority for Northern Ireland (2008) Infection Control and Hygiene Inspections. On-line. Available at infection_control_and_hygiene_inspections.cfm. Accessed 22 nd December Regulation and Quality Improvement Authority for Northern Ireland (2009) Infection Control and Hygiene Inspections. On-line. Available at infection_control_and_hygiene_inspections.cfm. Accessed 22 nd December Welsh Healthcare-Associated Infections Sub-Group (2009) National Infection Control Policies On-line. Available at ( Accessed 22 nd December

31 BIBLIOGRAPHY Belfast Health & Social Care Trust (2007) Corporate Management Plan. Belfast Health & Social Care Trust (2007) Environmental Cleanliness Strategy. Belfast Health & Social Care Trust (2008) Infection Prevention & Control Management Arrangements Policy. Belfast Health & Social Care Trust (2009) HCAI Recovery Plan. Belfast Health & Social Care Trust (2009) Delivery Plan 2009/10. Belfast Health & Social Care Trust (2009) Infection Prevention & Control Training Strategy Belfast Health & Social Care Trust (2009) Infection Prevention & Control Team Work Plan 2009/2010. Department of Health (2008) Clean, Safe Care: Reducing Infections and Saving Lives. London, DoH. Department of Health Social Services and Public Safety (2008) Programme for Government Belfast, DHSSPS. Department Health & Social Services Public Safety (2008) The Northern Ireland Regional Infection Prevention and Control Manual. Belfast, DHSSPS. Available for download at: Department of Health Social Services and Public Safety (2009) Championing the Management of Healthcare Acquired Infection: Guide for Students, Mentors/ Supervisors and Employers. Belfast, DHSSPS. Downloaded from Department of Health Social Services and Public Safety (2009) Controls Assurance Standards: Infection Control. Belfast, DHSSPS. Available for download from: -_version_2009_-_pdf.pdf Department of Health Social Services and Public Safety (2009) Folder of Evidence of Learning. Belfast, DHSSPS. Downloaded from Department Health & Social Services Public Safety (2009) Priorities for Action , Belfast, DHSSPS. Health Information and Quality Authority (2009) National Standards for the Prevention and Control of Healthcare Associated Infections. Dublin, HIQA. National Health Service, Quality Improvement Scotland (2007) The Clinical And Cost Effectiveness Of Screening For Meticillin Resistant Staphylococcus Aureus (MRSA). Edinburgh, NHS Quality Improvement Scotland. National Patient Safety Agency (2007) National specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes. London, NPSA. National Patient Safety Agency (2009) National specifications for cleanliness in the NHS: ambulance trusts. London, NPSA. Northern Ireland Ambulance Service, Health and Personal Social Services Trust (2006) Universal Precautions & Hand Washing Policy July

32 Northern Ireland Ambulance Service Health and Social Care Trust (2008) Infection Control Committee Cleaning Policy & Procedures (Draft Version). Northern Ireland Ambulance Service Health and Social Care Trust (2009) Cleanliness Policy. Northern Health & Social Care Trust (2007) Accountability Structure. Northern Health & Social Care Trust (2008) Infection Prevention & Control Training Strategy for Healthcare Workers. Northern Health & Social Care Trust (2009) Infection Control Policy Manual. Pratt, R.J. et al. (2007) Epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 65S, S1 S64. Scottish HAI Taskforce (2004) The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection. Edinburgh: Scottish HAI Taskforce. South Eastern Health and Social Care Trust (2008) Clostridium Difficile Management Policy. South Eastern Health and Social Care Trust (2008) Infection Prevention and Control Induction. South Eastern Health and Social Care Trust (2008) Trust Delivery Plan South Eastern Health and Social Care Trust (2009) Infection Reduction Plan South Eastern Health and Social Care Trust (2009) Adult Empirical Antimicrobial (Antibiotic) Therapy Guidelines for Inpatients. South Eastern Health and Social Care Trust (2009) Memo Re: IPC Policy and Regional Policy Manual. Southern Health and Social Care Trust (2009) Healthcare Associated Infection Prevention And Control Improvement Plan. Southern Health and Social Care Trust (2009) Guidelines on the Prevention, Control and Management of C.difficile Associated Disease (Draft version 1.3). Southern Health and Social Care Trust (2009) HCAI Improvement Plan and Associated Workstreams The Foundation Programme Committee of the Academy of Medical Royal Colleges, in co-operation with Modernising Medical Careers in the Departments of Health. (2005) Curriculum for the Foundation Years in Post-graduate Education and Training. Available for download at: lum.pdf Welsh Assembly Government (2004) Healthcare Associated Infections A Strategy for Hospitals in Wales. Cardiff, WAG. Western Health and Social Care Trust (2008) Draft Infection Prevention Control Delivery Plan Version 20. Western Health and Social Care Trust (2009) Executive Priority Assurance Framework. 31

33 World Health Organisation (2009) WHO Guidelines on Hand Hygiene in Health Care. Geneva, WHO. 32

34 WEBSITES SOURCED

35 APPENDIX ONE Regulation Quality and Improvement Authority: Summary of unannounced hygiene inspections The Regulation and Quality Improvement Authority (RQIA), a non-departmental public body with a statutory duty to assess and report on the availability and quality of health and social care services in Northern Ireland, conducted a programme of unannounced hygiene inspections of hospitals across Northern Ireland between March 2008 and September Eighteen inspections were carried out by RQIA between March 2008 and September Reports from these inspections provide a snapshot of hygiene and infection control standards at each of the hospitals through direct observations of the areas visited, some observations of clinical practice, staff and patient questioning and a review of key documentation in the wards and departments visited. Taken together, the eighteen reports demonstrate evidence of good practice in most hospital wards and clinical areas inspected. However, evidence of poor practice was also identified under the following themes: Environment and facilities The majority of the areas inspected in relation to the environmental section of the hygiene inspections achieved minimal compliance (68%). The standard of cleanliness varied between different areas of the hospitals inspected and in many instances it was attention to detail, at high and low levels, that was of concern and cluttered environments which restricted optimal cleaning at times. Concerns regarding general areas (entrances, corridors and general equipment) included dust and debris on the floor corners of wards and bays, the undercarriage of bed frames and patient trolleys. In many areas no policy existed for pre-planned curtain changing. Handling and Disposal of Linen Twenty six (41%) departments inspected in relation to the handling and disposal of linen achieved a compliance score. However, 59% were either partially or minimally compliant. Instances of poor practice noted include untidy linen rooms, inappropriate storage in linen rooms and uncovered blankets being stored on the floor. In addition, staff changing facilities were unavailable in many areas with staff using toilet areas for changing. 34

36 Departmental Waste Handling and Disposal Although the majority of wards and departments inspected generally demonstrated high standards in the handling and disposing of waste, 65% achieved a partial or minimal compliance score. Instances of poor practice included chemicals used by the domestic staff not always stored in accordance with COSHH Regulations with some domestic stores cluttered with inappropriate storage of equipment. Equipment used by the domestic staff was also found to be dirty and dusty in some departments. Concerns were also identified by some members of staff who stated they had not received recent training in the management of waste. Safe Handling and Disposal of Sharps The majority of the areas inspected in relation to the handling and disposal of waste were partially or minimally compliant (63%). However, twenty four (37%) areas inspected did achieve a compliance score. In some areas full sharps bins were stored in the dirty utility where patient consultations and observations were performed. In one instance inspectors found a syringe with medication inside which had been left unattended in a resuscitation area. Other concerns related to the fact that posters for the management of an inoculation injury were not always displayed at any of the areas inspected. Management of Patient Equipment (General) The majority of the areas inspected in relation to the management of patient equipment section of the inspections were either partially or minimally compliant (62%). Only twenty five (38%) out of the sixty five areas inspected achieved a compliance score. Although the majority of equipment in the areas observed was visibly clean, some equipment such as dressing trolleys, trolleys housing patient equipment and resuscitation trolleys were dusty and areas storing patient equipment were untidy and cluttered in places. In other cases suction tubing and catheters were left exposed with oxygen tubing trailing on the floor. Some areas did not have a separate sink for the decontamination of patient equipment. There were several concerns relating to decontamination such as staffs lack of knowledge that the Infection Control Team should be contacted prior to purchasing new equipment. 35

37 Hand Hygiene Thirty four (52%) out of the sixty five areas inspected in relation to hand hygiene achieved a compliance score with sixteen (25%) areas achieving partial compliance. However, fifteen (23%) areas only achieved minimal compliance. Concerns identified included the lack of availability of hand washing facilities and alcohol soaps and gels in some departments/areas. In other instances, although alcohol hand rub containers were widely available, these were empty when checked by inspectors. Hand washing sinks in ward bays were sometimes blocked by equipment which restricted access. In addition, members of staff questioned confirmed that not all patients were routinely offered hand washing facilities prior to meals. Similarly, some instances where members of staff did not wash or decontaminate hands after patient contact and inappropriate use of gloves by staff members was observed. Ward/Departmental Kitchens The majority of the areas in relation to the kitchen section of the inspections achieved a minimal (60%) or partial compliance score (23%). Only nine (17%) out of the fifty three areas inspected achieved a compliance score. The lack of thorough effective cleaning of fixtures, fittings, floors, inaccessible areas, food trolleys and surfaces was evident in the majority of areas inspected. In addition, in many areas food stored in the fridges was not labelled or dated and fridges did not have a thermometer with no recording of temperature readings. In some instances cleaning materials and equipment were stored beside food in kitchen areas. Clinical Practices It was encouraging to note that the majority of the areas inspected in relation to the clinical practices section of the inspections achieved a compliance score (73%). However, 27% of areas inspected achieved either partial compliance or minimal compliance. Not all staff members questioned had attended any recent training in relation to infection control or were aware of the online Regional Infection Control Manual and how to access the e- learning infection control programme. In addition, leaflets on infection prevention or Health Care Associated Infections were not always available or clearly visible. Inspectors also noticed improper use of gloves and plastic aprons on many occasions. Similarly, the use of sterile jugs versus 36

38 socially clean jugs for emptying catheter bags was an area of concern identified by inspectors. 37

39 APPENDIX TWO Aim of the Review AIM AND OBJECTIVES OF THE REVIEW 3.1 The aim of the initiative is to complete a review of HSC Trust staff training and development needs for infection prevention and control. Objectives of the Review 3.2 The objectives of the review are to: I II. Review UK government related web-sites (including the DHSSPS) to scope strategies and policies related to infection prevention and control, including training of health and social care staff. Analyse the policies of the 6 NI HSC Trusts in relation to infection prevention and control to identify best practice. III.Analyse HSC Trust Infection Control and Training Plans. (Objective 9, DHSSPS Changing the Culture Action Plan, 2006) to identify best practice. IV V VI VII Investigate levels of compliance with the standard set in Objective 10 of the DHSSPS Changing the Culture Action Plan, % coverage for induction training of all new staff by 1 April 2007 and all existing staff by 1 April 2008 and review ongoing activities. Scope infection prevention and control training within Northern Ireland Consider systems used by HSC Trusts to record training of staff in infection prevention and control In collaboration with an Expert Reference Group 1, recommend best practice in relation to training and development to address core training for all staff, additional training for all staff with a clinical remit 2, and training for staff with a specialist remit for infection prevention and control. VIII Submit a report to the DHSSPS by December It is intended that the reference group will comprise, as a minimum, Trust nominated members of each HSC Trust Infection Prevention and Control Team 2 This will not include staff who work in specialised high risk environments 38

40 APPENDIX THREE MEMBERSOF THE NIPEC REVIEW TEAM Lesley Barrowman (Chair) Brenda Devine Angela Drury Cathy McCusker Dr Carole McIlrath Frances McMurray Senior Professional Officer Senior Professional Officer Senior Professional Officer Senior Professional Officer Senior Professional Officer Chief Executive 39

41 APPENDIX FOUR NIPEC REVIEW TEAM TERMS OF REFERENCE 1. Oversee implementation of the plan for the review. 2. Take action to ensure the objectives for the review are achieved 3. Analyse relevant IPC literature and information to support the review objectives 4. Communicate with and manage the meetings of the Expert Reference Group and other related Sub-Groups 5. Collate information from the Expert Reference Group and Sub Groups to inform the final report 6. Write a report for submission to the DHSSPS 40

42 APPENDIX FIVE MEMBERS OF EXPERT REFERENCE GROUP Name Organisation Belfast Health & Social Care Trust June Champion IPC team line manager (dual role) Denise Killough Allied Health Protection representative Irene Thompson Senior IPC Nurse Dr Edward Smyth Microbiologist Caroline Smyth IPC nurse band 7 Northern Health & Social Care Trust Lorraine Crymble IPC nurse band acting band 7 Dr Peter Flanagan Medical Director Pat McKee Senior IPC Nurse South Eastern Health & Social Care Trust Isobel King Senior IPC Nurse Monica Merron Senior IPC Nurse Eamon Nancarrow IPC nurse band 6 Dr Ciaran O Gorman Medical Director Southern Health & Social Care Trust Dr Damani Clinical Director Maggie Markey IPC nurse band 7 Maria Tynan Allied Health Prevention representative Western Health & Social Care Trust Dr Christopher Armstrong Infection Control Doctor Cairine Gormley Antimicrobial Pharmacist Fiona Hughes Senior IPC Nurse Claire Robertson IPC Nurse Ambulance Service Tom McGarey Risk Manager Dr David McManus Medical Director Dr Nigel Ruddell Assistant Medical Director DHSSPS Patricia Blackburn Allied Health Profession Officer Veronica Callaghan Social Service Officer Anne Mills Nursing Officer Others Hazel Baird Professional member, NIPEC Council Marie O Hare Lay member, NIPEC Council 41

43 Dr Lourda Geoghegan Monica Graham Mary Hanrahan Irene Thompson Medical Director, Public Health Agency Health Protection Nurse, Public Health Agency Secretary,NI Infection Prevention Society Chair, NI Infection Prevention Society 42

44 APPENDIX SIX Expert Reference Group Terms of Reference 1. Provide information to the NIPEC Team regarding Trust IPC policies 2. Assist the NIPEC Team in scoping the Trust IPC training plans and implementation. 3. Advise the NIPEC Team regarding compliance of each Trust with Objective 10 in Changing the Culture (2006). 4. Advise the NIPEC Team regarding best practice in IPC training in relation to: Core training for all staff Additional training for staff with clinical remit Additional training for staff responsible for maintaining a clean environment Additional training for staff with Trust wide responsibility for IPC, including quality auditors Additional training for specialist IPC staff 5. Assist the NIPEC Team in identifying gaps in current Trust training plans and programmes. 43

45 APPENDIX SEVEN PROPOSED TRAINING PROGRAMME FOR NON CARE STAFF AND VOLUNTEERS All non-care staff and volunteers Intended participants: Level of training Core for all non-care staff and volunteers corporate induction awareness training 1hr Length of training Who delivers training IPC Team, identified trainers, commissioned training provider. Aim To ensure that all non-care staff and volunteers in the Trust understand their responsibility in relation to infection prevention and control. Objectives/ learning outcomes At the end of the session each person will have an awareness of: principles of infection prevention and control, including the chain of infection current issues in relation to infection prevention and control roles, responsibilities and accountability of staff in relation to infection prevention and control standard infection control precautions to prevent the spread of infections and disease the risks of Health Care Associated Infections (HCAIs) and how these can be minimised in different environments Indicative content 1. Why have Infection Control how germs are spread. Infection control is everyone s responsibility Personal responsibilities/staff health. Chain of organisational accountability for IPC 2. Reducing the Spread of Infection Basic hygiene, respiratory etiquette, cleaning Hand Hygiene: how, when, why Dress code Awareness of why not to come to work with vulnerable clients/pts/residents if unwell Publicity/public awareness/litigation/consequences of HAI for family patient + provider Speak to the Nurse/person in charge before visits. Basic decontamination / cleaning Awareness of local policies. Phones, computer keywords available Steps of decontamination washing /cleaning disinfection. 0

46 3. Health and Safety Infection Control manual. Basic sharps awareness/ health + safety -Sharp object don t lift it. Challenging practice - Knowing what to do if you witness. Spillage or sharp not disposed of correctly Ensure awareness if blood fluid spills are found they ensure that this is addressed/dealt with; who to contact for IPC advice + how. Recognition of isolation signage/ basic PPE 4. Waste Disposal Basic waste disposal. Differences between household/clinical waste and segregation Community /Hospital differences Mode of delivery A one hour face-to-face training session. Each participant will have access to user friendly reference materials on the Trusts intranet and other identified internet sites to use as required. An electronic/hard copy self-assessment should be completed prior to training and repeated within one week of the training session. Updates Every two years for individuals accessing or regularly entering a building in which care is provided. 1

47 PROPOSED TRAINING PROGRAMME FOR ALL CARE STAFF APPENDIX EIGHT Intended participants: Basic Training Secondary Level All staff with a potential to engage in direct Staff with additional responsibilities for patient contact invasive procedures. Level of Training: Basic Training Secondary Level Basic understanding and ability to apply Additional information to inform higher level principles clinical decision making and clinical skills Level of Training: Basic Training Secondary Level 1½ hours Additional 1 hour Who delivers Training: Health and Social Care Trust Infection Prevention and Control Team, identified trainers, commissioned training provider. Who delivers Training: To understand safe and effective evidence-based practices through education and training in infection prevention and control in order to minimise the risk of HCAI. Objectives/ learning outcomes Basic Training Secondary Level At the end of the session each person will be able to demonstrate: 1. An understanding of local Trust IPC structure, health and safety legislation, personnel & policies. 2. An understanding of the risks of HCAIs and how these can be minimised through transmission based precautions. 3. An ability to correctly apply principles of IP&C, including basic microbiology, methods of spread, chain of infection, colonisation/infection & decontamination. 4. An understanding of all aspects of standard precautions including hand hygiene. 5. An understanding of multi resistant organisms and other alert organisms and their management. 6. An understanding of current infection prevention and control issues. 7. An understanding of the importance of personal responsibility including health, hygiene and dress code 1. An understanding of transmission-based precautions for specific diseases. 2. An understanding of the practitioner s role in relation to antimicrobial resistance and the importance of correct antibiotic delivery. 3. An understanding of the principles of procedure and associated risks for invasive interventions and treatments. 2

48 Indicative content Basic Training Secondary Level Role of IPC Team Principles of procedure and associated Chain of infection risks for invasive interventions and Standard Infection Control Precautions treatments. Hand hygiene Specimen Collection: Personal Protective Equipment Blood cultures Laundry management Arterial blood collection Safe handling and disposal of Preventing the Risk of Microbial Clinical waste Contamination and Outbreak Control Safe handling and disposal of Root cause analysis sharps blood borne viruses Management of multi-resistant Environmental Cleanliness organisms Transmission based precautions Antimicrobial stewardship and Health and Safety Legislation and administration COSHH Immunology Decontamination: Surveillance Of environment (including Clinical governance spillages) Audit Of equipment Decontamination: Personal health and hygiene Risk assessment Dress code Policies and procedures Food hygiene and pest control Specimen collection Aseptic Non-Touch Technique (ANTT) Emerging diseases: e.g. Avian flu, SARS, A/H1N1 May require different scenarios to be raised with relevance to community staff, residential home staff and CSSD staff Mode of Delivery Face-to-face training E-learning Each participant will have access to user friendly reference materials on the Trusts intranet and other identified internet sites to use as required. An electronic/hardcopy competence self-assessment tool should be carried out at an agreed time following training and any additional training needs addressed. This should be repeated in line with annual appraisal systems. Updates Updates for both basic and secondary levels biennial. 3

49 For further Information, please contact NIPEC Centre House 79 Chichester Street BELFAST, BT1 4JE Tel: Fax: January