Radiology IFC Programme 2009-2010

SCOTTISH HOSPITAL LIVINGSTONE

Private Bag 001, Molepolole Telephone: 5908000

Document name: Infection prevention and control programme 2009-2010 Document no: SLH-RAD-IFC-PRO-001 Section: Radiology Revision no: 001Reviewed by: Document review committee Review date: 02/07/09

Copy control no: 20 Page no: 1 of 16

Revision HistoryRevision no Description of change Author Effective date001 Change to New Template Infection prevention and control committee:

Ms Godirwang BojosiMr. Jafar AhmedMs Rudo Murwira

04/06/09

Name Position Signature Date

Approved by Felly Masole Nursing Officer I (Infection control nurse)Authorized by Dr Davis Makwinja Principal Medical Officer(Chairperson IFC)

SCOTTISH HOSPITAL LIVINGSTONE Document no: SLH-RAD-PRO-001

Document name: Infection prevention and control programme 2009-2010 Revision no: 001 Page no: 2 of 16

IntroductionPrevention of nosocomial infections requires an integrated, monitored, programme which includes the following key components:

Limiting transmission of organisms between patients and direct patient care through adequate hand washing, glove use and appropriate aseptic practice, isolation strategies, sterilization and disinfections practices and laundry.

Controlling environmental risks for infection. Protecting patients with appropriate use of prophylactic antimicrobials, nutrition and vaccinations. Limiting the risk of endogenous infections by minimizing invasive procedures, and promoting optimal antimicrobial use. Surveillance of infections, identifying and controlling outbreaks. Prevention of infection in staff members. Enhancing staff patients care practices, and continuing staff education.

Infection control is the responsibility of all health care professionals- doctors, nurses, therapist, pharmacists, engineers, laboratory technicians and others.

PurposeThe purpose of this document is to set minimum hospital standards in the effective prevention and management of hospital acquired infection and identifies and reduces the risk of transmitting infection among patients, staff, volunteers, students and visitors.

ScopeThis document shall be applicable to all staff in Scottish Livingstone Hospital, all health care providers and health care students.



Definition of terms 1. Nosocomial infection: An infection acquired in a health care facility by a patient/client, staff or visitors to the health care facility. Such

infection should have not been present at the time of admission/initial contact with the health facility.2. Disinfections: A process of reducing microbial load through use of process or chemical agent to destroy pathogens but not bacterial spores.3. Infection control committee: A multidisciplinary group formed to deal with infection prevention and control issues

4. Infection control programme: A programme that involves/encompasses all aspects of infection prevention and control covering education and training, waste and environmental management, disease outbreak investigation, development of infection control policies, guidelines and protocols, cleaning, employee health, monitoring and evaluation.

5. Personal protective equipment: Refers to all items specifically used to protect health care workers for exposure to blood and body fluids or droplet and airborne infection

6. Sterilization: A process of destroying all viable micro organisms including spores through use of steam, heat, gas or chemicals. 7. Waste management:

SIZE AND GEOGRAPHIC LOCATION OF THE HOSPITALRadiology department is located within Scottish Livingstone Hospital (SLH) which is a district hospital situated in Kweneng District in Molepolole village in the southern part of Botswana, approximately 60km from Gaborone. The village has a population of approximately 70 000 and act as gate way to the Kalahari Desert.



VISIONTo establish a quality and excellent programme to prevent and control nosocomial infections within Radiology environmentMISSIONTo ensure that departmental acquired (nosocomial) infections are prevented and controlled within the unit environment and community we serve.

MOTTOPrevention is better than cure.

SLOGANInfection control is everybody’s business

COORDINATION OF INFECTION CONTROL ACTIVITIESInfection prevention and control of Radiology department will be coordinated and directed by the unit infection control committee which consists of the following:

1. Focal person: Ms Godirwang Bojosi 2. Member: Mr. Jafar Ahmed3. Member: Ms Rudo Murwira.



Roles and Responsibilities

The role of infection prevention and control committee

- Identify the health care establishment’s needs in terms of infection prevention and control, waste management, food safety and central sterilization. This includes the need for training and education within the facility.

- Priorities the needs and develop an infection prevention and control strategic plan. This strategic plan and recommendation for adequate funding must be presented to the management.

- Monitor the implementation of the infection prevention and control strategic plan- Identify structural needs for the infection prevention and control inputs in the location of suitable hand washing facility, soap and

alcohol dispensers, waste storage facility, isolation rooms, food handling areas and laundry.- Ensure regular cleanliness surveys are conducted and review reports of such surveys are prepared.- Adapt infection prevention and control policies and precautions to local needs.- Develop facility infection prevention and control manual.-



The role of infection control focal person is the same as for infection control unit but performed at local level.

- Supervise and coordinate all infection prevention and control activities to ensure effective programme- Collaborate with the IFC unit in developing programme for supervising the use of antibiotics- Ensure that patient care practices concerning infection control are appropriate- Provide expert advice, analysis and leadership in outbreak investigation and control- Check the efficacy of the methods of disinfecting and sterilization and the efficacy of system developed to improve hospital

cleanliness.- Participate in the development and provision of infection prevention and control training and orientation programmes for all unit staff

- Provide possible assistance for smaller facilities linked to the hospital.- Undertake research in the hospital hygiene and infection prevention and control at the facility and at unit level.- Prepare an essential equipment list and identify immediate and long term equipment needs for infection prevention and control.- Organize training and education programmes for staff- Supervise isolation.- Assist the infection control committee in developing facility infection prevention manual- Oversee waste management, food handling, unit cleanliness, sterilization of equipment, and advise on purchasing of hospital

cleaning and disinfecting chemicals- Evaluate adherence to infection prevention and control standards and policies periodically.- Identify health care associated infections- Surveillance of unit infections

- Develop infection prevention and control policies and guidelines- Maintain the infection prevention and control equipment inventory and infection control records



PROCESS TO REDUCE INFECTION RISK

Standard precautions are the measures that must be applied as routine principles by all staff working in the clinical environment at all times. These principles assumes that all blood and body fluids are potentially infected and the possibility that the immediate environment may also be potentially contaminated.These processes include: A comprehensive nosocomial infection risk reduction programme is in place Correct hand washing Wearing of protective clothing when dealing with body fluids Treating all blood and body fluids as infected Proper disposal of waste and excreta safely to prevent contamination Standard colour coding for waste disposal in place



Covering any broken skin Use and dispose of sharps in a safe and appropriate manner. Disinfections of body fluids spillages to deactivate blood borne viruses. Good isolation guidelines Promoting early detection of infection through active surveillance and monitoring to reduce chances of cross infection Standardized environmental cleaning.

Use of colour coding of mops in place. Availability and implementation of infection prevention and control policies and guidelines. Management VHF Handling and disposal of blood and blood product Infection control quality improvement process in place An infection control orientation in- service training in place at unit. Awareness of infection control posters in place



LIST OF GUIDELINES/ SOP’S IN PLACE Hand washing Equipment cleaning, disinfections and sterilization. Laundry and linen management. Disposal of infectious waste. Disposal of clinical waste. Food handling, storage . Separation of patients with communicable diseases from patients and staff. Management of viral hemorrhagic fever. Handling and disposal of blood and blood components. Personal protective equipment. Specimen collection, transportation and action to be taken when pathogenic organism is identified(environmental).

QUALITY IMPROVEMENT PROJECT IN PLACE Hand hygiene compliance Waste management (clinical and domestic waste) Proper use of Personal protective equipment.



THE FOLLOWING ACTS AND REGULATIONS AND LITERATURE GUIDES US:

1. Botswana clinical waste code of practice2. Botswana National Health policy3. COHSASA guideline

IDENTIFIED NON-CLINICAL AREAS- INFECTION RISK

HIGH RISK AREA MEDIUM RISK LOW RISK AREASPublic areas e.g. waiting areas Staff changing rooms OfficesAll toilets, sluice rooms KitchenHouse keeping



IDENTIFIED NON- CLINICAL AREAS INFECTION RISKSHIGH RISK AREAS

Unit/ department

Infection risks Preventive measures Guidelines/policies Education/training Monitoring

Housekeeping/ Segregation of waste

- Needle prick- Blood and body fluids- Infections- Poor environmental hygiene- Poor cleaning of waste storage containers- Wrong use of waste containers- Poor segregation of waste-Poor transportation of waste

-Proper waste management/ Hepatitis B vaccination-Use of PPE:(Gloves,Masks, plastic aprons)-Hand washing-Environmental hygiene-Proper decontamination of waste storage containers -Use right colour coded waste bags

- Guideline for Hepatitis B vaccination-Universal precautions.-Hand washing SOP- Personal protective equipment SOP-Waste management SOP-Post exposure prophylaxis SOP-Hepatitis B vaccination

Infection controlWaste management, Handling of different waste, Handling spillage, Pest control

Audit toolReportStatistics QI inspection rounds

Remedial action

All toilets, visitors and staff

- Dirty toilets- No toilet paper- Poor waste management

- Maintenance programme- Cleaning programme- SHE bins in place- Supply of stock

- House keeping- Cleaning programme.- Hand washing

-Infection control cleaning education

- QI inspection rounds- Supervisor daily audit rounds

Air conditioners

- Poor maintenance- Poor control of cleaning of filters

- Regular maintenance- Filter and cleaning programme

- Maintenance programme in place

- Infection control - QI inspection rounds

- Poor hygiene(water evaporation)

- Cleaning of water evaporation areas



IDENTIFIED NON- CLINICAL AREAS INFECTION RISKSHIGH RISK AREAS

Units/ department


Public areas, e.g. waiting areas

- Poor hygienic environment.

- Poor waste disposal- Poor hand washing.- Poor maintenance

- Regular cleaning,- Proper waste management- Maintenance programme

- House keeping SOP- Waste management SOP - Cleaning programme- Maintenance programme

- Health & safety- Housekeeping education

QI audit rounds



CLINICAL AREAS Unit/ department


ALL CLINICAL AREAS

Non-adherence to hand washing policy

- Adhere to hand washing policy- Do in-service training to all staff on importance of hand washing- Place washing posters at all strategic areas- Ensure that hand washing facilities are available at all hand washing basins- Do awareness campaigns twice a year

- Hand washing SOP- Posters on hand washing

- On policy on hand washing.- Awareness campaign

- Audit tools- Quality rounds- QIP on hand washing

Non-adherence to universal precaution/ standards( Blood and body fluids)

- Proper utilization of PPE (i.e. gloves, masks, goggles, plastic aprons).- Do proper hand washing before and after.

- Universal standard precautions- Hand washing SOP- Posters on hand washing

- Use of PPE- Correct hand washing

- Audit tools- Quality audit rounds- Remedial actions

Incorrect use of PPE - Proper use of PPE- Wear gloves if coming in contact with patient- Wear masks/goggles for splashes- Plastic apron for

- PPE SOP- Correct gloving procedure

- Use of PPE- Hand washing technique

- Audit tools- Quality audit rounds- Remedial actions

Lack of isolation facility

- All patients with infectious diseases to be isolated.- Isolation measures to be followed at all times

- SOP on isolation of patients with infectious diseases- Hand washing SOP- Posters on isolation

- Inform the relevant department about the patient

- Audit tools- Management walk about- Quality rounds


Document name: Infection prevention and control programme 2009-2010 Revision no: 001 Page no: 14 of 16CLINICAL AREAS

Unit/ department


ALL CLINICAL AREASCont…

Improper disposal of waste

- Ensure proper disposal of waste according to color coding- Segregate waste at source

- Waste management SOP- Posters displayed

- Proper waste disposal- Use of color coded bags

- Audit tools- Quality audit rounds- Remedial actions.- QIP

Sharps injury ( needle pricks)

- Proper disposal of sharps- Correct use of sharps containers and readily available- Never attempt to re-sheath needle after use- Dispose of used needles and syringes as unit- Dispose of used needles and syringes immediately after use

- Universal standard precautions- Sharp disposal SOP

- Use of PPE- Proper sharps disposal

- Audit tools- Spot teaching- Quality rounds

Poor handling of soiled and used linen

- Linen to be sorted at the source i.e. at the patient’s bed side.- Scoop off any visible organic matter, e.g. faeces, blood clots.- Canvas bags should be readily available- Never put linen on the floor- Do not overfill canvas bag

- SOP on linen management- Hand washing SOP- PPE SOP

- On linen management- Hand washing

- Audit tools- Quality rounds and inspections

- Wet the soiled linen under cold running water and put into color coded plastic bag.- Use the PPE when handling linen- Wash hands



CLINICAL AREASUnit/ department


ALL CLINICAL AREASCont…

Blood and body fluid spills

- Cover the spill with paper towel to prevent spread of fluid.- Utilization of necessary equipment i.e. unsterile latex gloves, paper towel, plastic refuse bag, hypo chlorite detergent

- Spillage SOP- Use of PPE

- Training on how to clean spillages procedure on blood and body fluid spillage

- Audit tools- Management walk about

Insufficient cleaning and decontamination of beds, mattresses and x-ray couch

- Clean bed rails daily and mattresses in-between patients and/ or on discharge with hypo chloride detergent

- SOP on cleaning of beds/ stretchers/ coaches

- Cleaning on beds/ stretchers/ trolleys

- Audit tools- Remedial actions

Insufficient cleaning of equipment e.g. ultra sound probes

- Wipe probes with 70% alcohol before and after use

- SOP on decontamination

- Cleaning of equipment

- Audit tools- Quality inspection rounds

Pest and rodent infestation

- Ensuring good housekeeping practices- Quarterly fumigation- Food

- Fumigation programme- SOP on pest control

- Good house keeping- Pest and rodent infestation

- Quality inspection rounds - Audit tool

- SOP on food hygiene

SCOTTISH HOSPITAL LIVINGSTONE Document no: SLH-IFC-PRO-001


CLINICAL AREASUnit/ department


Poor housekeeping practices (window, curtain, cubicle cleaning and dusting)

- Cubicles must be cleaned from clean areas to contaminated areas i.e. sluice areas and toilets must be cleaned last.- Screen curtains must be changed every 3 months or immediately when dirty or have body fluid splashes- Dusting and high dusting must be done with a damp cloth daily after sweeping of the floor. Precept/hypo-chlorite detergent solution must be used to decontaminate.- Hand basins, showers, baths, toilets must be cleaned daily.

- SOP on cleaning of the floors- SOP on washing of the curtains

- Good house keeping - Decontamination audit tool- Quality inspection rounds

Spills and splashes (Body fluids)

- Proper utilization of PPE (i.e. gloves, masks, goggles, plastic aprons).- Do proper hand washing before and after.- Wear masks/goggles for splashes- McIntosh aprons

- Spillage SOP- Use of PPE- Post Exposure prophylaxis procedure

- Use of PPE- Proper sharps disposal

- Audit tools- Spot teaching- Quality rounds

Radiology IFC Programme 2009-2010

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