Infection Prevention and Control (incorporating surveillance of alert organisms and sharing of information) PDF Free Download

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 SECTION: 18 INFECTION CONTROL POLICY /PROCEDURE: 18.05 NATURE AND SCOPE: SUBJECT: POLICY AND PROCEDURE - TRUST WIDE INFECTION PREVENTION AND CONTROL (incrprating surveillance f alert rganisms and sharing f infrmatin) This plicy and prcedure details the arrangements fr the preventin and cntrl f infectin. DATE OF LATEST RATIFICATION: SEPTEMBER 2017 RATIFIED BY: EXECUTIVE LEADERSHIP TEAM IMPLEMENTATION DATE: OCTOBER 2017 REVIEW DATE: OCTOBER 2020 ASOCIATED TRUST POLICIES AND PROCEDURES: Hand Hygiene - 18.04 MRSA - 18.07 Decntaminatin f Patient Equipment -18.01 Use f Antimicrbial Medicatin 19.04 Occupatinal Expsure t Bld Brne Viruses -18.06 Management f Waste 16.08 Transfer f Patients with Knwn/Suspected Infectin - 18.09

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL POLICY AND PROCEDURE (incrprating surveillance f alert rganisms and sharing f infrmatin) 1.0 INTRODUCTION 1.1 Nttinghamshire Healthcare NHS Fundatin Trust (NHCT) recgnises that it has a duty f care t prtect patients, staff, cntractrs and visitrs frm healthcare assciated infectin (HCAI) and supprts the need fr effective systematic arrangements fr surveillance, preventin and cntrl. It is therefre cmmitted t reducing the incidence f HCAI and, mre imprtantly, t prevent the risk f avidable infectin. 1.2 Within the NHS natinal and lcal targets have been set t reduce the incidence f HCAI and varius dcuments have been prduced by the Department f Health (DH) t prvide rganisatins with a framewrk t enable this reductin t ccur. The dcuments are listed in sectin 16 belw. The latest f these is, The Health and Scial Care Act: Cde f Practice n the Preventin and Cntrl f Infectins and Related Guidance 2008 (Revised 2015). This is the first time infectin preventin and cntrl (IPC) and its imprtance has been embedded within legislatin. This prvides a framewrk t enable rganisatins plan and implement measures t prevent and cntrl infectins. 1.3 NHCT has declared cmpliance with the HSCA 2008. Mnitring f cmpliance with the Act is n-ging. It is undertaken internally by the Trust thrugh adherence t this plicy and the IPC Assurance Framewrk and Wrk Plans and externally by the Care Quality Cmmissin. 1.4 The criteria listed belw are the Cde f Practice. Cmpliance with the 10 criteria will demnstrate that the Trust is taking the necessary measures t prvide gd quality, safe care t its service users and staff. a) Systems t manage and mnitr the preventin and cntrl f infectin. These systems use risk assessments and cnsider the susceptibility f service users and any risks that their envirnment and ther users may pse t them. b) Prvide and maintain a clean and apprpriate envirnment in managed premises which facilitates the preventin and cntrl f infectins. c) Ensure apprpriate antimicrbial use t ptimise patient utcmes and t reduce the risk f adverse events and antimicrbial resistance. d) Prvide suitable, accurate infrmatin n infectins t service users, their visitrs and any persn cncerned with prviding further supprt r nursing / medical care in a timely fashin. e) Ensure prmpt identificatin f peple wh have r are at risk f develping an infectin s that they receive timely the apprpriate treatment and care t reduce the risk f transmitting infectin t ther peple. f) Systems t ensure that all care wrkers (including cntractrs and vlunteers) are aware f and discharge their respnsibilities in the prcess f preventing and cntrlling infectins. g) Prvide r secure adequate islatin facilities. h) Secure adequate access t labratry supprt as apprpriate.

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 i) Have and adhere t plicies designed fr the individual s care and prvider rganisatins that will help t prevent and cntrl infectins. j) Prviders have a system in place t manage the Occupatinal health needs and bligatins f staff in relatin t infectin. 1.5 This plicy will prvide assurance fr cmpliance with CQC utcmes 8: Cleanliness and Infectin Cntrl, Regulatin 12, that states Peple shuld be cared fr in a clean envirnment and prtected frm the risk f infectin. 2.0 POLICY/ PROCEDURE PRINCIPLES 2.1 This plicy identifies NHCTs respnsibilities fr the preventin and cntrl f HCAIs as legislated in the HSCA 2008 (Revised 2015). 2.2 This is an ver-arching plicy intended t utline hw NHCT will manage the brad and cmplex issues with regard t IPC in accrdance with relevant legislatin, DH directives and evidence based research and best practice. 3.0 DEFINITIONS Patient: this term is used when referring t the NHS ppulatin as a whle. A healthcare facility is a hspital, clinic, utpatient department r residential nursing hme which prvides medical and related services aimed at maintaining gd health, especially thrugh the preventin and treatment f disease. Care staff refers t bth health and scial care staff, Risk is the chance f an undesirable utcme. Risk includes cnsideratin f bth the likelihd and severity f the utcme (Health, Safety and Welfare Plicy Plicy Ref: 16.01). A hazard is smething that has the ptential t cause harm (Health, Safety and Welfare Plicy HS/GS/01). Healthcare Assciated Infectins (HCAI), are thse that arise during any cntact with healthcare, either in hspital r in the cmmunity setting, whether in patients themselves r in the health r scial care wrker undertaking interventin Infectin Preventin and Cntrl is the preventin and management f infectin thrugh the applicatin f research based knwledge t practices that include standard precautins, decntaminatin, waste management, surveillance and audit. Alert rganisms are thse identified as psing a public health risk t patients, staff and visitrs defined by the Department f Health (DH 1995). 4.0 DUTIES 4.1 The Trust Bard The Trust Bard has verall respnsibility fr ensuring that there are effective arrangements and adequate resurces prvided fr IPC within the Trust and fr mnitring the impact f the plicies f the Trust. 4.2 The Chief Executive

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 The Chief Executive has verall respnsibility fr ensuring that there are effective management and mnitring arrangements prvided fr IPC t meet all statutry requirements. 4.3 The Directr f Infectin Preventin and Cntrl (DIPC) The DIPC will have verall respnsibility fr IPC and will reprt directly t the Chief Executive and the Bard quarterly and as required. The DIPC is an integral member f the Trust s clinical gvernance safety structure The DIPC has verall respnsibility fr the IPC infrastructure and management f the IPC teams The DIPC versees lcal infectin cntrl plicies and their implementatin and als has authrity t challenge inapprpriate clinical practice as well as antibitic prescribing decisins. The DIPC prduces the IPC annual reprt. This is presented t the Trust Bard tgether with the annual IPC Prgramme f wrk fr Bard apprval. The DIPC will chair the Trust Wide Infectin Preventin and Cntrl Cmmittee 4.4 The Trust Wide Infectin Preventin and Cntrl Cmmittee A Trust Wide Infectin Preventin and Cntrl Cmmittee is a mandatry requirement. It is a key frum in prviding assurance that the Trust has in place structures and arrangements t meet all statutry requirements fr IPC The purpse f the Trust Wide IPC Cmmittee is t appraise the Chief Executive, the Clinical Gvernance Cmmittee and the Trust Bard n issues relating t IPC within the Trust, in particular t highlight, in advance where pssible, ptential prblems and risks (See Appendix 1 fr the full Terms f Reference). NHCT has plicies, prcedures and guidelines in place fr the diagnsis, preventin, surveillance and cntrl f infectin. IPC plicies and prcedures are develped, maintained and mnitred fr the Trust by the Trust Wide IPC Cmmittee. In shared premises r where the service is prvided via service level agreements, the ther Trusts Prcedures and Plicies will be adpted. This must be agreed by all parties. 4.5 Antimicrbial Steward The designated Antimicrbial Steward leads the Trusts prgramme f wrk designed t ensure the apprpriate and safe use f antimicrbials. The Steward is supprted by clinical pharmacists with input frm micrbilgy t ensure all aspects f antimicrbial stewardship are met. The Antimicrbial Steward is a member f the Trust Wide Infectin Preventin and Cntrl Cmmittee. 4.6 Directrs, Assistant Directrs, Clinical Directrs, General Managers Directrs, Assistant Directrs, Clinical Directrs and General Managers are respnsible fr ensuring the cmpliance with all relevant criterins f the Health and Scial Care Act 2008 (Revised 2015) within their Divisin s and lcalities They must als:

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 Ensure that Heads f Service/Senir Nurses/Matrns prvide a three mnthly prgress reprt t their Divisinal IPC Grup. Ensure that all IPC related peratinal matters raised by Heads f Service/Senir Nurses/Matrns/Senir Clinical Practitiners/Allied health Prfessinals in their area are reviewed and actined Fllwing risk assessments r audits, they must ensure adequate allcatin f resurces t facilitate remedial actin. 4.7 The Infectin Preventin and Cntrl Team There are tw Divisinal IPC Teams within the Trust as utlined in Appendix 2. The IPC teams (IPCT) manage, develp, plan and implement a cmprehensive IPC service fr NHCT. They are respnsible fr: The Trust Assurance Framewrk and assciated Wrk Plans Prviding a management, cnsultative and advisry service t the Trust in rder that the Trust ensures effective systems are in place fr the mnitring, preventin and cntrl f infectin and ensure cmpliance with the Health and Scial Care Act 2008 (Revised 2015). Prvide specialist advice and supprt fr staff, patients, carers and visitrs in rder t reduce the risk t patients, staff and the public f avidable HCAIs. Undertaking rutine surveillance f alert rganisms t mnitr trends, detect utbreaks and increased prevalence Disseminatin/sharing f surveillance data t relevant parties as requested Mnitring and respnding t utbreaks f infectin Leading a prcess f Rt Cause Analysis (RCA) r Pst Infectin Review (PIR) fr all incidents f MRSA bacteraemia, Clstridium difficile infectin, Clstridium difficile deaths, e cli bacteraemia and utbreaks f infectin Sharing the learning frm the RCA/PIR t infrm changes t practice Ensuring that the recmmended IPC plicies and clinical practice guidance are reviewed and updated as required. All plicies and clinical practice guidance will reflect natinal guidance and ther relevant evidence based practice. See appendix 3 fr a cmprehensive list f the Trust IPC Plicies and Prcedures Prviding IPC training fr all staff apprpriate t their rle Undertake an extensive prgramme f clinical audit f healthcare envirnments and clinical practice Ensuring that infectin preventin and cntrl is cnsidered within all relevant Estates and Facilities t ensure the prvisin and maintenance f a clean and apprpriate health care envirnments. Wrk clsely with the Occupatinal Health Department and ther relevant stakehlders t develp Plicies and Guidelines fr the prtectin f all Trust

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 emplyees frm expsure f cmmunicable infectins during the curse f their wrk. Develp and prduce an annual IPC wrk prgramme with clearly defined bjectives Assist the DIPC with the writing f the annual IPC reprt which utlines the prgress f the prgramme. Attend wrking grups acrss the health ecnmy t share learning and implement standardised practice acrss services 4.8 Senir Nurses/Mdern Matrns/Clinical Nurse Managers Senir Nurses/Mdern Matrns/Clinical Nurse Managers are respnsible fr: Reprting t the Divisinal IPC Grups n a quarterly basis t prvide evidence f all IPC related activity Wrking clsely with Department/Ward Managers and Infectin Cntrl Link Persnnel t ensure identified IPC actins are achieved e.g. audits, RCA/PIR utcmes 4.9 Department/Ward Managers Department/Ward Managers are respnsible fr ensuring the implementatin f advice, plicies and prcedures within their department. This includes: Being respnsible fr the inclusin f IPC in every relevant emplyee s inductin and persnal develpment plan Inclusin f IPC respnsibilities in every relevant emplyee s jb descriptin and cntract f emplyment. Ensuring all secnded staff, bank and agency staff and any cntracted wrkers are made aware f all plicies and prcedures related t IPC during lcal inductin. Ensuring that all staff attend relevant IPC training sessins, f which recrds are t be maintained 4.10 The Infectin Preventin and Cntrl Link Prfessinals / Practitiners The Infectin Preventin and Cntrl Link Prfessinal (ICLP) acts as a facilitatr f gd IPC practice within their area f wrk. The ICLP acts as a link between the IPC Service and their clleagues. The ICLP will: Attend quarterly meetings and feedback the infrmatin gained t clleagues, managers and ther health care prfessinals Act as a resurce fr clleagues, patients and the public Participate in IPC clinical audits Participate in IPC prmtins and campaigns 4.11 Respnsibilities f all Emplyees

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 All emplyees are respnsible fr ensuring that they undertake relevant IPC training available t them. All emplyees f the Trust have a duty f care t adhere t all Trust plicies and prtcls applicable t IPC. All emplyees wh are secnded t NHCT, all bank and agency staff tgether with any cntractrs emplyed by the Trust will be persnally accuntable fr their actins and are respnsible fr ensuring that they cmply with IPC plicies and prcedures. It is the respnsibility f emplyees invlved in patient care t ensure that they utilise safe wrking practices as utlined in IPC plicies and prcedures. Any breach in IPC plicies r practice will place staff, patients and visitrs at risk. All emplyees invlved in the care f patients with HCAIs must ensure they are aware f the plan fr managing the HCAI and cmplete all relevant dcumentatin as required All emplyees have a duty t act n and reprt t the IPCT, at the earliest pprtunity, an infectin that may be deemed infectius t thers i.e. cmmunicable/ntifiable diseases r resistant rganisms r ptential utbreak 5.0 DISSEMINATION OF INFORMATION 5.1 Infrmatin available t patients, service users and the public abut the Trust arrangements fr the preventin and cntrl f HCAIs can be fund n the Trust s Intranet site in the frm f the IPC Annual Reprt and Annual Prgramme f wrk, alng with lcal area specific infrmatin leaflets. 5.2 The Trust has a Transfer f Patients with Knwn/Suspected Infectin Plicy 18.09. The plicy cntains a Transfer f Care frm that must be cmpleted when patients are transferred frm ne health care setting t anther. 5.3 Learning frm rt cause analysis and any ther IPC incidents will be shared within the Trust and acrss rganisatins within the health cmmunity. 6.0 IMPLEMENTATION ARRANGEMENTS 6.1 The respnsibility fr implementing this plicy rests with the manager respnsible fr each individual r grup f staff. Managers are required t ensure that all staff are aware f the plicy and are able t practice in accrdance with the requirements f this. 7.0 TRAINING 7.1 The Trust is cmmitted t make available resurces t supprt the training requirements f all emplyees in IPC. 7.2 The training needs f individual members f staff will be identified as part f the Perfrmance Appraisal and Develpment prcess. 8.0 TARGET AUDIENCE 8.1 This plicy applies t all staff wrking within the Trust and shuld be used in cnjunctin with ther relevant plicies and guidelines 9.0 REVIEW DATE

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 9.1 This plicy will be reviewed every 3 years r in the event f rganisatin changes r new DH guidelines r legislatin. 10.0 CONSULTATION The Trust Infectin Cntrl Cmmittee Divisinal Infectin Cntrl Grups Infectin Preventin and Cntrl Teams Health and Safety Cmmittee Executive Leadership Cuncil. 11.0 MONITORING COMPLIANCE 11.1 Untward incident reprts, serius untward incident reprts, sharps incidents and HCAI surveillance and assciated activity will be discussed by the lcal Infectin Cntrl Grups which meet at a minimum quarterly and als at Trust-wide Infectin Cntrl Cmmittee which meets quarterly. 11.2 Matrns and Clinical Directrs are t reprt quarterly t the Trust Bard n Infectin Cntrl and Cleanliness via the Divisinal IPC Cmmittees 11.3 Lessns learned frm incidents and gd practice will be shared via the apprpriate channels including the IPC cmmittees, lcal team meetings and shared with the health ecnmy as relevant. 11.4 Infectin Cntrl audits f clinical areas will be undertaken. The audit plan is reviewed annually and updated accrdingly. Actin plans will be develped as necessary and reviewed by the Divisinal IPC Grups. 12.0 EQUALITY IMPACT ASSESSMENT 12.1 This plicy has been assessed using the Equality Impact Assessment Screening Tl. The assessment cncluded that the plicy wuld have n adverse impact n, r result in the psitive discriminatin f, any f the diverse grups detailed. These include the strands f disability, ethnicity, gender, gender identity, age, sexual rientatin, religin/belief, scial inclusin and cmmunity chesin. 13.0 LEGISLATION COMPLIANCE The Health and Safety at Wrk Act 1974 The Health and Scial Care Act 2008. Cde f Practice fr the NHS n the Preventin and Cntrl f Health Care Assciated Infectins and related guidance. 14.0 CHAMPION AND EXPERT WRITER 14.1 The Champin fr this plicy is Julie Attfield, Executive Directr fr Nursing. The Expert Writer is, Janine Patricksn-Daly, Trust Infectin Preventin and Cntrl Lead 15.0 RELEVANT TRUST POLICIES & PROCEDURES 15.1 See appendix 3.

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 16.0 REFERENCES AND SOURCE DOCUMENTS Department f Health (2015) The Health and Scial Care Act 2008. Cde f Practice fr the NHS n the Preventin and Cntrl f Healthcare Assciated Infectins and related Guidance. Lndn. Department f Health Department f Health (2007) Unifrms and Wrk Wear An Evidence Base fr Develping Lcal Plicy. Lndn. Department f Health Department f Health (2005) Saving Lives: A Delivery prgramme t Reduce Healthcare Assciated Infectin, including MRSA. Lndn. Department f Health Department f Health (2006). Essential Steps t safe clean care: Reducing Healthcare Assciated Infectin. Lndn. Department f Health Department f Health (2004) A Matrns Charter - An Actin Plan fr Cleaner Hspitals.. Lndn. Department f Health Natinal Institute fr Health and Care Excellence. (2014). Infectin Preventin and Cntrl. NICE Quality Standard 61

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 TRUSTWIDE INFECTION CONTROL COMMITTEE TERMS OF REFERENCE 2017-18 APPENDIX 1 1.0 INTRODUCTION T meet current standards in Infectin Preventin and Cntrl, Nttinghamshire Healthcare NHS Fundatin Trust requires sufficient designated persnnel, representing different parts f the Trust, with clear respnsibilities, adequate lines f cmmunicatin and ther resurces t facilitate the effect f preventin, detectin and cntrl f infectin. 2.0 INFECTION PREVENTION AND CONTROL STRUCTURE Pre Trustwide Infectin Preventin and Cntrl Meeting Trustwide Infectin Preventin and Cntrl Cmmittee Divisinal Infectin Preventin and Cntrl Grups 2.1 The Chief Executive has ultimate respnsibility fr effective infectin preventin and cntrl in the Trust and shuld ensure that apprpriate resurces are available. 2.2 The Executive Directr (Nursing, Quality and Patient Experience) is the identified lead fr infectin preventin and cntrl n the Trust Bard and is the designated Directr f Infectin Preventin and Cntrl (DIPC). 2.3 Whilst strategic leadership f infectin preventin and cntrl is the respnsibility f the DIPC, peratinal respnsibilities are held with the Assciate Directrs (Nursing, Quality and Patient Experience) Frensic and Lcal Partnership Divisins. 2.4 Infrmatin will be cascaded thrugh Assciate Directrs (Nursing, Quality and Patient Experience), divisinal IPC leads fr nward circulatin. 3.0 MEMBERSHIP OF THE INFECTION CONTROL COMMITTEE Executive Directr f Nursing (Chair) Medical Staff representative Chair f Divisinal Infectin Preventin and Cntrl Grups (Assciate Directrs f Nursing) Divisinal Infectin Preventin and Cntrl Lead (Frensic Divisin) Divisinal Infectin Preventin and Cntrl Lead/Trustwide Lead (Lcal Partnerships) Trust Health and Safety Manager Chief Pharmacist Head f Emergency Preparedness & Respnse (EPRR) Cnsultant Micrbilgist/ Cmmunity Infectin Cntrl Dctr Suth Nttinghamshire 4.0 PURPOSE

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 4.1 T appraise the Quality Cmmittee t Bard n issues relating t infectin preventin and cntrl within the Trust, in particular t highlight, in advance where pssible, ptential prblems and risks. 4.2 T receive reprts as fllws: 4.2.1 The Divisinal Infectin Preventin and Cntrl Grups 4.2.2 Surveillance data n Healthcare Assciated Infectins 4.2.3 Serius untward incidents 4.2.4 Assurance Framewrk 4.2.5 Training 4.2.6 Sharps 4.2.7 Fd Hygiene 4.2.8 Antimicrbial Stewardship T identify any risks which need t be escalated t the Quality Cmmittee 4.3 T mnitr the Trust cmpliance with the Health and Scial Care Act 2015, Cde f Practice n the Preventin and Cntrl f Infectins and related guidance (Hygiene Cde). 4.4 T initiate and ratify reviews f Trust Infectin Preventin and Cntrl plicies, prcedures and apprve guidance. 4.5 T review and advise n lcal, natinal and internatinal dcuments relating t infectin preventin and cntrl and their impact n the Trust. 4.6 T apprve annual infectin preventin and cntrl prgrams f wrk t be undertaken in Divisins fr apprval by the Bard. 4.7 T review and discuss majr service, plicy and capital develpments and their impact n infectin preventin and cntrl. 4.8 T identify needs and recmmendatins fr the educatin and training f all staff in infectin preventin and cntrl. 4.9 T prduce an annual infectin preventin and cntrl reprt. 4.10 T review and escalate assciated risks. 4.11 T have versight ver IPC capacity. 5.0 FREQUENCY 5.1 The Trust Infectin Preventin and Cntrl Cmmittee shall meet quarterly. 6.0 QUORUM 6.1 N business shall be transacted unless at least 4 members f the grup are present and must include either the chair r deputy chair. 7.0 ATTENDANCE

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 7.1 All members require 75% attendance ver the year. On ccasins when nminated members are unable t attend they will send a named deputy. Other individuals will be c-pted t the grup as required. 8.0 REPORTING ARRANGEMENTS 8.1 The Infectin Preventin and Cntrl Cmmittee shall reprt t the Trust Bard via the Quality Cmmittee. Additinally, the Executive Directr f Nursing reprts t the Bard mnthly IPC KPIs. The Trust Bard directly receives the Trust Annual IPC Reprt. 9.0 REVIEW A review f the terms f reference will take place annually. Reviewed 6 July 2017: circulatin t cmmittee members 6 July 2017. Ratificatin 11 th September 2017

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 APPENDIX 2 INFECTION PREVENTION AND CONTROL INFRASTRUCTURE AND REPORTING ARRANGEMENTS Nttinghamshire Healthcare Trust Bard Risk Management Cmmittee Trust Wide Infectin Preventin and Cntrl Cmmittee Lcal Partnerships Infectin Preventin and Cntrl and Cntinence Grup

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 INFECTION PREVENTION AND CONTROL POLICIES AND PROCEDURES APPENDIX 3 18.01 Decntaminatin f Equipment Plicy 18.02 Obtaining Clinical Samples fr Micrbilgy Prcedure 18.03 Outbreak f Infectin Prcedure 18.04 Hand Hygiene Plicy & Prcedure 18.05 Infectin, Preventin and Cntrl (inc. surveillance f ALERT rganisms and sharing f infrmatin) Plicy 18.06 Occupatinal Expsure t Bld Brne Viruses Plicy and Prcedure 18.07 Meticillin-Resistant Staphylcccus aureus (MRSA) Preventin & Cntrl Plicy 18.08 Leginellae Cntrl Plicy 18.09 Transfer f Patients with Knwn/Suspected Infectin Plicy 18.10 Islatin Plicy 18.11 Safe Management & Dispsal f Sharps Plicy 18.13 Management f Clstridium difficile Infectin (CDI) Plicy & Prcedure 18.14 Aseptic Nn Tuch Technique Plicy 18.15 Tuberculsis Preventin and Cntrl Plicy 18.16 Management and Cntrl f Carbapenemase-Prducing Enterbacteriaceae (CPE) 18.17 Pest Cntrl Plicy 18.18 Scabies Management Plicy 18.19 Management f Patients with Extended Spectrum Beta-lactamase (esbl) Prducing Clifrms 18.20 Crrect Use f Persnal Prtective Equipment (PPE) in the Clinical Setting 18.21 Bld and ther Bdy Fluid Spillages Plicy and Prcedure 18.22 Grup A Streptcccus Infectin Management and Cntrl Plicy 18.23 Care f the Deceased Patient 14

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 EQUALITY IMPACT ASSESSMENT (EIA) SCREENING TOOL (Twards an Equality and Recvery Fcused Organisatin) APPENDIX 4 A. Name f plicy/prcedure/strategy/plan/functin etc. being assessed: B. Brief descriptin f plicy/prcedure/strategy/ plan/functin etc. and reasn fr EIA: C. Names and designatins f EIA grup members: D. List f key grups/rganisatins cnsulted: E. Data, Intelligence and Evidence used t cnduct the screening exercise: INFECTION PREVENTION AND CONTROL (incrprating surveillance f alert rganisms and sharing f infrmatin) This plicy and prcedure details the arrangements fr the preventin and cntrl f infectin. The plicy identifies NHCTs respnsibilities fr the preventin and cntrl f HCAIs as legislated in the HSCA 2008 (Revised 2015). This is an ver-arching plicy intended t utline hw NHCT will manage the brad and cmplex issues with regard t IPC in accrdance with relevant legislatin, DH directives and evidence based research and best practice. J Patricksn-Daly, Trust Lead Infectin Preventin and Cntrl IPC Teams Health and Scial Care Act 2015. Cde f Practice n the preventin and cntrl f infectins and related guidance 15

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 F. Equality Strand Des the prpsed plicy/prcedure/ strategy/ plan/ functin etc. have a psitive r negative (adverse) impact n peple frm these key equality grups? Please describe Race Gender Inclu. Transgender and Pregnancy & Maternity Disability Religin/Belief Sexual Orientatin Incl. Marriage & Civil Partnership Age Scial Inclusin* 1 There is n impact psitive r negative in respect f Race. Applicatin f the plicy is dependant entirely n clinical presentatin. As abve in respect f gender, inclusive f transgender There is n impact psitive r negative in respect f Disability with regard t applicatin f the plicy. Nne There is n impact psitive r negative in respect f Religin/Belief, with regard t applicatin f the plicy. There is n impact psitive r negative in respect f Sexual rientatin, with regard t applicatin f the plicy. There is n impact psitive r negative in respect f Age, with regard t applicatin f the plicy There is n impact psitive r negative in respect f scial Are there any changes which culd be made t the prpsals which wuld minimise any adverse impact identified? What changes can be made t the prpsals t ensure that a psitive impact is achieved? Please describe Have any mitigating circumstances been identified? Please describe Areas fr Review/Actins Taken (with timescales and name f respnsible fficer) NA NA Plicy t be reviewed inside current agreed timescales led by the authr. NA NA As abve NA NA As abve NA NA As abve NA NA As abve NA NA As abve NA NA As abve 16

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 Cmmunity Chesin* 2 Human Rights* 3 inclusin, with regard t applicatin f the plicy There is n impact psitive r negative in respect f cmmunity chesin, with regard t applicatin f the plicy There is n impact psitive r negative in respect f Human Rights, with regard t applicatin f the plicy NA NA As abve NA NA As abve * 1 fr Scial Inclusin please cnsider any issues which cntribute t r act as barriers, resulting in peple being excluded frm sciety e.g. hmelessness, unemplyment, pr educatinal utcmes, health inequalities, pverty etc. * 2 Cmmunity Chesin essentially means ensuring that peple frm different grups and cmmunities interact with each ther and d nt exclusively live parallel lives. Actins which yu may cnsider, where apprpriate, culd include ensuring that peple with disabilities and nn-disabled peple interact, r that peple frm different areas f the City r Cunty have the chance t meet, discuss issues and are given the pprtunity t learn frm and understand each ther. * 3 The Human Rights Act 1998 prevents discriminatin in the enjyment f a set f fundamental human rights including: The Right t a Fair Trial; Freedm f Thught, Cnscience and Religin; Freedm f Expressin; Freedm f Assembly and Assciatin; and the Right t Educatin. G. Cnclusins and Further Actin (including whether a full EIA is deemed necessary and agreed date fr cmpletin) H. Screening Tl Cnsultatin End Date I. Name and Cntact Details f Persn Respnsible fr EIA (tel. e-mail, pstal) J. Name f Grup Apprving EIA (i.e. Directrate E&D Grup; Divisinal Wrkfrce, Equality & Diversity Grup; Trustwide E&D Subcmmittee; r Divisinal Plicy & Prcedures Grup) NA 5:00pm n Friday 15 September 2017 Janine Patricksn-Daly Trust Lead Infectin Preventin and Cntrl Janine.patricksn-daly@nttshc.nhs.uk Mbile: 07972 655091 West Bridgfrd Office: 0115 8837319 (Direct Dial) Equality and Diversity Subcmmittee f the Bard f Directrs 17

Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) 18.05 APPENDIX 5 Plicy/Prcedure fr: Infectin Preventin and Cntrl (incrprating surveillance f alert rganisms and sharing f infrmatin) Issue: 08 Status: Authr Name and Title: APPROVED Janine Patricksn-Daly, Trust Lead Infectin Preventin and Cntrl Issue Date: OCTOBER 2017 Review Date: OCTOBER 2020 Apprved by: Distributin/Access: EXECUTIVE LEADERSHIP TEAM NORMAL DATE AUTHOR RECORD OF CHANGES POLICY/ PROCEDURE 10.07 I/C Team HS/GS/08 07.08 I/C Team HS/GS/08 DETAILS OF CHANGE Changes in legislatin, trust persnnel and in line with NHSLA standards and huse style Changes in legislatin and divisinal structures in trust. 11.09 A Kirkland HS/GS/08 Changes thrughut the dcument 11/11 02/12 N Murphy/ P Strazds/ J Patricksn- Daly N Murphy/ P Strazds/ J Patricksn- Daly 02/14 J Patricksn-Daly 08/17 J Patricksn-Daly 18.05 (issue 6) 18.05 (issue 6a) 18.05 (Issue 7) 18.05 (Issue 8) Changes thrughut the dcument t include CHP Minr change at sectin 4.5 Changes thrughut the dcument. Cmbined with the Surveillance f Alert Organisms. Sectin 1.4 updated with the revised Criterin Appendices 1, 2, 3 updated. Sectin amended t include Antimicrbial Stewardship. 18

Infection Prevention and Control (incorporating surveillance of alert organisms and sharing of information) 18.05