Infection Prevention and Control Policy N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document. Approved by: Infection Prevention & Control Committee Review by date: 30 July 2015
Contents: 1 Executive Summary...2 1.1 Scope of Policy...2 2 Aims...2 3 Policy Statement...3 4 Responsibilities...3 4.1 The Health Board & Directors...3 4.1.1 Executive Nurse Director...4 4.2 Divisional Nurses...4 4.3 Line Managers and Clinicians...4 4.4 All Employees...4 4.5 Infection Prevention Team...5 4.6 Infection Prevention Doctor...6 4.7 Infection Prevention Nurses...6 4.8 Consultant Occupational Health Physician and Department...6 5 Training...6 6 Monitoring and Effectiveness...7 7 Key References...7 8 Appendices...7 8.1 Terms of Reference Strategic Infection Prevention and Control Committee...7 8.2 Quality and Patient Safety Assurance Framework...7 Page 1
1 Executive Summary It is the policy of Aneurin Bevan Health Board to prevent and control infection, protecting patients, staff and visitors to the organisation. Healthcare Associated Infections A strategy for hospitals in Wales published in 2004 and subsequently Healthcare Associated Infections A community strategy for Wales (2007) highlighted the need to for all staff to understand the impact of infection and infection control practices to enable them to discharge their personal responsibilities to patients, other staff, visitors and themselves. The move away from infection control being seen as solely the domain of the specialist infection prevention team to infection control becoming everyone s business has begun, along with the shift towards a culture of zero tolerance where one avoidable infection is considered one too many. Whilst acknowledging that there has been considerable progress, the refreshed Welsh Strategy Commitment to Purpose Eliminating Preventable Healthcare Associated Infections has indicated that there is still much work to be done before a position is reached where preventable HCAIs are eliminated. This policy sets the direction for infection prevention and control within the Health Board and Standards for Health Service 13. The policy will ensure that infection prevention and control activity is supported, monitored and embedded within Divisions and Localities. Decontamination of reusable devices also falls under the remit of Infection Prevention and is addressed through the Aneurin Bevan Health Board Decontamination Strategy. 1.1 Scope of Policy The Infection Control Policy applies to all Health Board premises and property, patients, staff employed by the Health Board, visitors, contractors, subcontractors and all other persons engaged in business on behalf of the organisation. 2 Aims The Health Board: Is committed to an approach whereby prevention and control of infection is seen as part of all service delivery and development activity. Page 2
Is committed to working closely, in partnership, with other local healthcare providers and agencies to adopt and promote common good practice and procedure. Will work with other stakeholders to improve surveillance and to strengthen prevention and control of infection and communicable disease processes. Will ensure that appropriate resources are made available to support infection control activities and ensure this policy and guidelines are available throughout the organisation. Will ensure systems are in place to systematically assess infection risks. Will ensure, as appropriate, that staff receive relevant training in infection prevention and control. Will ensure that appropriate systems are in place for the surveillance of infection to meet local, regional and national guidelines. Will communicate information relating to infection risks and outbreaks to all relevant parties. 3 Policy Statement The Infection Control Policy is designed to: Promote a greater awareness of potential infection hazards for Health Board staff. Provide rationalised evidence based measures, which should be adopted to prevent and control infection. Recognise and implement multi-disciplinary co-operation to provide a co-ordinated approach, in order to minimize acquisition and transmission of infection, where each employee plays a part. Embrace Patient Safety programmes such as the 1000 Lives Plus programme. 4 Responsibilities 4.1 The Health Board & Directors The Chief Executive accepts on behalf of the Board ultimate responsibility for all aspects of Infection Prevention and Control. Page 3
4.1.1 Executive Nurse Director The Executive Nurse Director accepts delegated responsibility for Infection Control who will lead on the organisational agenda for eliminating HCAI. 4.2 Divisional Nurses Divisional Nurses are accountable to the Chief Executive for ensuring all staff within their respective divisions fully understand and implement the Infection Prevention & Control Policy. They will ensure, so far as is reasonably practicable that: There are adequate resources available to meet infection prevention and control requirements. All managers are competent to discharge their infection and control responsibilities. The effectiveness of the policy and the arrangements for implementing the policy are regularly evaluated and discussed with the appropriate personnel. 4.3 Line Managers and Clinicians All line managers and clinicians are responsible for: Ensuring that the requirements and recommendations of the policy are met within their department. Implementing the policy within their area of responsibility. Ensuring that all their staff receive appropriate training in the policy and have the necessary knowledge to practice safe infection control procedures. Ensuring regular evaluation of the policy and procedures as practised in their area of responsibility. Liaising with the Infection Prevention Team, who will assist them with the above. 4.4 All Employees Whilst at work, employees have a duty to: Take reasonable care of their own health and safety at work and of other persons who may be affected by their acts or omissions this includes adherence to infection control recommendations of preventative measures to minimise transmission to others. Page 4
Report hazards in the workplace (including infection control hazards). To participate in training that is offered to them. 4.5 Infection Prevention Team The Infection Prevention Team is accountable directly to the Executive Director of Nursing, who takes delegated responsibility for infection control for the Chief Executive of the Organisation. The Infection Prevention Team must be available to report to the Executive Nurse Director on all matters relating to the infection prevention & control policy. The team is required to: Work with Senior and Line Managers to distribute the Policy. Audit and evaluate compliance with and effectiveness of the Policy; Be available to provide advice and guidance to any member of staff on the Policy or issues relating to it. The Infection Prevention Team Consultant Microbiologist & Lead Infection Prevention Doctor, Organisation wide. Base: Nevill Hall Hospital Consultant Microbiologist & Infection Prevention Doctors, Royal Gwent Hospital Lead Nurse, Infection Prevention Team Decontamination Manager Senior Nurse, Infection Prevention, Royal Gwent Hospital Senior Nurse, Infection Prevention, Nevill Hall Hospital Senior Nurse, Infection Prevention, Community, Mental Health & LD 2 x Band 6 Infection Prevention Nurses, Royal Gwent Hospital 1 x Band 6 Infection Prevention Nurse, Nevill Hall 1 x Band 6 Infection Prevention Nurse, Community, Mental Health & LD Page 5
1 x Band 5 Secondment Band 4 Admin. Support Officer - Base: Nevill Hall Band 3 Admin. Support Base: Royal Gwent In addition to the core team five locality nurses take responsibility for monitoring the infection control agenda in the wider community, including GP surgeries, and care homes. 4.6 Infection Prevention Doctor The Infection Prevention Doctor is accountable to the Executive Director of Nursing and ultimately the Chief Executive of the Organisation for advising and reporting on all matters relating to infection control. He/she is responsible for developing, and reviewing infection control policy, and for chairing the Infection Prevention & Control Committee. 4.7 Infection Prevention Nurses The Infection Prevention Nurses work in partnership with the Infection Prevention Doctor. They assist with policy development, implementation and systematic review. They are responsible for the support and education of patients, visitors and staff. 4.8 Consultant Occupational Health Physician and Department The Occupational Health Department with the Infection Prevention Team provide advice to staff on measures to avoid the transmission of infection between staff and patients. The Occupational Health Department would advise managers and employees on immunisation policies, and, in liaison with the Infection Prevention & Control Team would apply the Health Department's guidelines in drawing up policies on immunisation against infectious disease. The Consultant Occupation Physician would provide information and advice if necessary to the Organisation's Chief Executive and Medical Director on staff who carry out exposure prone procedures and contract blood borne viruses. 5 Training The Infection Prevention Team provides training on all policies within the infection control manual. Training to specific wards/departments/areas is offered to all employees. A generic session can be accessed monthly though the Training and Development prospectus. Page 6
Through surveillance and audit the Infection Prevention Team may identify areas of non-compliance with the Infection Prevention and Control Policy. This will be fed back to the staff concerned and their manager. If lack of understanding of any infection control policy is identified, specific training on the policy will be made available to the staff. It is important that the ward manager or delegated member of staff makes the infection control manual known to any new staff member. If staff training is arranged to address non-compliance or identified training needs staff must be allocated time to attend. The Infection Prevention Team will develop a training session(s) to meet individual ward/divisional requirements. 6 Monitoring and Effectiveness The key committee for monitoring infection control arrangements is the Infection Prevention and Control Committee, (Terms of Reference Appendix 1) Infection Prevention will be monitored through the Quality and Patient Safety Assurance Framework Appendix 2. Unresolved Infection Prevention and Control issues will be escalated to the Quality and Patients Safety Committee. 7 Key References Welsh Government (2011) Commitment to Purpose: Eliminating preventable healthcare associated infections (HCAIs) A framework of actions for healthcare organizations in Wales Welsh Government (2007) Healthcare associated infections a community strategy for Wales Welsh Government (2004) Healthcare Associated Infections A Strategy for Hospitals in Wales 8 Appendices 8.1 Terms of Reference Strategic Infection Prevention and Control Committee 8.2 Quality and Patient Safety Assurance Framework Page 7
APPENDIX 1 Aneurin Bevan Health Board INFECTION PREVENTION AND CONTROL TEAM TERMS OF REFERENCE Strategic Infection Prevention and Control Committee Introduction Although the Infection Prevention Team carries the prime responsibility for infection prevention and control, it cannot effectively carry out its role in isolation. It needs collaboration and active support of other Health Board staff, as well as assistance from colleagues in external organisations. Many of the policies and procedures to be followed in individual departments or support activities relate, at least in part, to infection control requirements and these can only be drawn up by or with those with particular expertise in the needs and problems of those services. Moreover, they can only be implemented by the staff of those services, not by the Infection Control Team itself. Hence it is important that these staff have ownership of the policies. An organisation wide infection control programme, although drawn up by the Infection Control Team, will raise particular issues for different specialties and services. The Infection Prevention and Control Committee represent the main forum for strategic consultation between the Infection Control Team and the rest of the Health Board. The Operational Infection Prevention and Control Committee represent the main forum for operational consultation and will be served by separate Terms of Reference. The Strategic Committee s endorsement of and support for the Team s programme is essential. The minutes of the Infection Prevention and Control Committee will be widely circulated and made accessible to senior staff in all Divisions, Localities, Risk Management and Quality and Patient Safety Groups. The Strategic Infection Control Committee is accountable to the Quality and Patient Safety Committee and ultimately the Health Board. The Strategic Committee will meet quarterly and the Operational Committee bi-monthly. Extraordinary committees may be additionally convened for special purposes such as outbreak management. Page 8
Core Membership Strategic Infection Prevention and Control Committee Chair Lead Infection Control Doctor Executive Nurse Director for Infection Prevention and Control Non Officer Member for Infection Prevention and Control Assistant Medical Director for Quality Infection Control Doctor / Medical Microbiologist Lead Infection Prevention and Senior Infection Prevention Nurses Head of Health and Safety Divisional Nurses Consultant in Communicable Disease Control Senior Public Health Nurse Member of the Community Health Council Occupational Health Consultant Occupational Health Lead Nurse Divisional Director Facilities Decontamination Manager Strategic Lead Cleanliness Principal Functions of the Strategic Infection Control Committee The purpose and duty of the Strategic Infection Control Committee is to ensure that healthcare services within the organization are provided in a managed environment that: a) is well maintained and kept at acceptable national levels of cleanliness; b) minimises the risk of healthcare associated infections to patients, staff and visitors, aiming to achieve year on year reductions in incidence; and c) emphasises high standards of hygiene and reflect best practice initiatives. The structure exists to maintain an overview of infection control priorities within the organization, and to link this into the clinical governance and risk management processes. It will ensure that infection control issues are appropriately managed within the unit. Page 9
The Infection Control Committee will: Advise and support the Infection Control Team Provide accurate real time surveillance and outcome data which will feed the Annual Quality Framework and 1000 Lives Plus drivers. Monitor implementation of Infection Control Standards for Healthcare. Monitor the ABHB Overarching Infection Control Action Plan Identify infection risks and ensure appropriate action to minimize them. Bring to the attention of the Chief Executive and Board of Directors serious issues relating to the prevention and control of infection. Ensure that prevention and control of infection is considered as part of all service development activity. Promote and facilitate education of all grades and disciplines of staff in procedures for the prevention and control of infection Review and endorse policies, procedures and guidance for the prevention and control of infection and to monitor their implementation, ensuring that such policies reflect relevant legislation and published professional guidance. Support the organization in its legislative, accreditation, governmental and ethical obligations relating to infection control practice. Supervise a programme for the periodic audit of infection control policies and procedures. Review and endorse outbreak management plans Discuss and endorse the annual infection prevention and control programme, monitor progress of the programme and assist its effective implementation Present a quarterly Control of Infection Report to the Quality and Patient Safety Committee Present and Annual Infection Control Report to the Local Health Board. Page 10
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