North East Ambulance Service NHS Trust Infection Prevention and Control Annual Work Plan April 2009 March 2010 October review (2) No. Objective Actions Lead Date of 1 Leadership throughout Accountability Trust Board bimonthly the organisation by arrangements from the creating and Trust Board to Chief Executive embedding a culture of operational level improving patient DIPC safety and care from IPC will be an integral the Trust Board to all part of everyday work of IPC Manager staff employed within all Trust staff. To make IPC part of everyone s business and consistently apply IPC principles into the day to day working environment 2 Ensure the NEAS is compliant with the Care Quality Commission (CQC) registration criteria against The Health and Social Care Act 2008. 3 To reduce the risk to patients and staff of acquiring an infection, by ensuring staff comply with current evidence based best practice guidelines. Job descriptions will reflect roles and responsibilities of all grades of staff within the Identified clinical champions. quarterly the NEAS assessment plan against the 7 criteria applicable of the Code of Practice to monitor progress. NEAS to have robust IPC policies and procedures in place in line with latest evidence based practice. Policy available to all staff via NEAS intranet, Managers / Assistant Managers DIPC IPC Manager IPCC DIPC / IPC Manager / IPCC quarterly October 2009 to have identified champions On-going / outstanding Named station champions are required to ensure IPC is embedded within the culture of operational staff. Duties will involve audit. Responsibility operations Table of representatives produced and Professional Agreement draft document produced CQC inspection July 09 no breach in the regulations and therefore met the core standards related to infection control, decontamination and a clean well-designed environment. Passed 14 measures and given recommendations on 3. June 2009 August 2009 Policy ratified by JCC and Trust Board and will be available to staff by end of August 09. Sections currently covered in training sessions on IPC. Incorporated into induction & mandatory training programmes. 1
4 Clinical Procedures Incorporated into IPC Training and June 2009 Saving Lives High Impact Intervention protocols / policy workforce (HII) No. 2 Peripheral intravenous document to include development / IPC cannula care bundle part of training current guidance from Manager courses for Student Paramedics and the National Institute for part of statutory and mandatory Clinical Excellence training programmes (skills days) (NICE), EPIC and during 2009-10. Saving lives programme. Asepsis training utilising Aseptic Non Touch Technique (A.N.T.T) to be delivered to relevant staff groups as part of on-going training through Skills Days and Student Paramedic programmes. A.N.T.T. to be used during cannulation when ever possible to do so. Also incorporate into wound care. Single use equipment is kept sterile and in packaging until point of use. CPC issued with regard to single use equipment disseminated August 2009. Work with Purchasing officer /development of further plans for introduction of new products (wound care dressing packs, wound irrigation, pre-filled sodium chloride flush, sleeve protectors) 5 Education and training Induction module for IPC for new staff to the Generic IPC presentation to be delivered to all NEAS staff. This must include hand hygiene training. HR Induction. Training Department Statutory / Mandatory training. 2 Outstanding: Business case to be produced (October 2009) to include single use equipment, wound care packs/cleaning products On-going March 2010 Dates available for all training for 2009-10, IPC incorporated into Skills days. Training records held by training department and IPC Manager. KPI for HR department.
6 Reporting and Thorough investigation IPC Manager and On-going Mechanisms in place for this to take investigation of any and root cause analysis any other staff place. identified incident to be carried out by the member as which may have appropriate staff team identified through resulted in a patient or members. the investigation staff member acquiring process an infection through the 7 Ensure with hand hygiene protocol and introduction of the National Patient Safety Agency your 5 moments for hand hygiene Launch the next stage of the clean your hands campaign materials Ensure that hand hygiene is incorporated into all induction /statutory/ mandatory training sessions and include UV light box assessment. Handouts and posters for staff and display purposes available for stations via intranet IPC site. Ensure all staff carry personal issue alcohol hand rub. Alcohol hand rub available in dispensers on all A&E / PTS Vehicles. IPC / Hand hygiene Champion on each station within the IPC Manager / Team Leaders / Station champions / Communications department September 2009 Team leaders or other staff members based on stations are the Hand hygiene nominated champions. 3
8 To demonstrate that IPC Manger to excellent IPC practice have overall is taking place within direction with the NEAS and additional support promote clinical from ownership. (Audit and staff. inspection). (Recommendation 1 from the CQC) 9 a) Promote clean safe environment Buildings (recommendation 2 from the CQC) Observational audit in divisions to ensure with IPC Policy: Hand hygiene Sharps handling, disposing etc Cleaning vehicle/equipment including blood / body fluid spills ANTT cannulation, wound care Use of personal protective equipment including glove use Develop cleaning standards for NEAS buildings and stations. Liaise with estates / procurement re cleaning contractors and current service provision. Develop cleaning schedules / routines in line with NPSA National cleanliness standards for Ambulance Trusts. Identify clear definition of roles and responsibilities for cleaning Provision of cleaning materials at station level Audit programme Estates Manager Head of Procurement Purchasing Manager Management Team Leaders IPC Manager On-going Audit to be included as currently this is not adequately resourced 4 Audit tool available Responsibility divisions to work with IPC Manager Observational audits currently being undertaken by nominated staff representative Oct 2009 Overall cleaning of buildings and stations requires standardisation across the service and is making slow progress. Deep clean for all stations this needs to be done asap. Cleaning manual in draft, workshop planned for November with staff side reps to ensure the manual is achievable. Wall holders for cleaning schedules to be placed in sluice, store room, toilets and shower areas now in place cleaning strategy to be developed Patient Environment Action Group to be established Sluice areas Business case To be updated to include hand washing basin and consumables. Brackets to be in place to hold Non compliant
mop handles when not in use Danicentres to ordered and in stores now require wall mounting in sluice area Audit Clinical department to audit annually currently being undertaken and electronic tool being developed undertaken and for completion by mid November H&S reps monitor quarterly seeking agreement at December meeting OM/AOM/ TLs on-going monitoring of standards agreement to be sought No. Objective Actions Lead Date of b) Vehicles Develop cleaning standards for NEAS vehicles including A&E, RRV & PTS in line with NPSA cleanliness standards published in 2009. Increase the number of level 3 cleans per year crews to have operational responsibility on day to day basis for cleanliness of vehicles there are using Job description to reflect this Swabbing of vehicles by AHA following cleaning Divisional Support Manager / Assistant Support Manager IPC Manager crews Managers 5 On-going Additional ambulance hygiene assistants required to increase cleaning frequencies. KPI to monitor swabbing results of vehicles. Cleaning manual in draft and included cleaning frequencies and tasks for vehicle cleaning by crews further discussion required. Fleet had robust procedure for cleanliness performed by the Ambulance Hygiene Assistants (AHA).
Managers to swab vehicles randomly and results. OM/AOM to carry out random swabbing on vehicles - outstanding No. Objective Actions Lead Date of 10 Appropriate decontamination of instruments and other equipment. (recommendation 3 by the CQC) All re-usable equipment must be decontaminated after use. Single use equipment must remain in packaging until point of use. IPC Manager Clinical Department Staff 15 th October 2009 25 th September 2009 Equipment cleaning included in IPC procedures and cleaning manual. Covered in mandatory training programmes. Protocol to be developed for the cleaning and decontamination of ventilator tubing in line with manufacturer s instructions. All single use equipment which is out of packaging must be removed from response bags and vehicles by target date and replaced with new achieved August 2009. Responsibility of OM/AOM/TL to ensure this is carried out. 11 Links to external bodies Contribute to those IPC / HCAI groups within the NEAS divisions to work across the whole health economy. Attend the National IPC Ambulance Service Group. IPC Manager 6
12 Assurance Framework which demonstrates that IPC is integral part of clinical and corporate governance. Regular presentations from the DIPC/IPC Team including s of HCAI surveillance data from the SHA, outbreaks and any serious untoward incidents. Commissioning of NEAS performance targets as identified. Trust Board DIPC / IPC team Risk Department Performance Lead On-going monitoring Robust audit programme required for monitoring and developing of further KPI for IPC. Ensure with the Health and Social Care 2008 is included in the NEAS corporate risk register CQC inspection : no breaches on the regulations therefore compliant with the Health and Social Care. Evidence of appropriate action taken to deal with occurrences of infection, (root cause analysis/investigation s). Key performance indicators (KPI) for IPC to monitor progress and direct any actions required. KPI outstanding further clarification to be sought Risk register to reflect any identified IPC risks to the organisation. monitoring through the audit programme. Trust fails to comply with current legislation in particular The Health and Social Care Act 2008 (the Code of Practice) and best practice guidance. Green = Achieved Amber = ongoing progress against Red= not achieved no evidence against 7