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Infection, Prevention & Control
Annual Report 2014 - 2015
Compiled by: Donna Eldridge, Deputy Director of Nursing / Deputy DIPC
Rod Harford-Rothwell, Senior Infection Control Nurse
Prepared on Behalf of Pippa Barber, Director of Nursing & Governance Director of Infection Prevention and control (DIPC)
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Contents Page Number
1. Forward
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2. Executive Summary
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3. Introduction
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4. Structure, Accountability and Assurance
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5. Reporting Mechanisms
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6. The Health & Social Care Ace (2008) Code of Practice/Assurance Framework
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7.
Policies 7
8. Clinical Audit and Effectiveness
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9.
Antimicrobial Prescribing and Management 17
10.
Training and Education 17
11.
Link infection control nurse/Workers
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12.
Needle stick / Sharps Injuries 18
13.
Outbreaks of Diarrhoea and Vomiting including Norovirus
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14. MRSA Screening
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15. Decontamination
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16.
Commodes 21
17.
Flu Campaign 21
18.
Conclusion 21
Appendix A – Assurance Framework
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1. FORWARD
I am pleased to present the annual infection prevention control report for 2014/15. The following report will provide an overview of Infection Prevention and Control (IPC) activities in Kent and Medway NHS & Social Care Partnership Trust and sets out the plans for the forthcoming year using the assurance framework. Infection Prevention and Control is one of the fundamental aspects of safe service delivery and everyone within the organisation, service users, carers and visitors to our services have a vital role to play in reducing the risk of spreading infection. As the Director of Infection Prevention and Control (DIPC), both I and the Infection Prevention control Team continue to be committed to ensuring that patient safety is at the forefront of everything we do. I commend this annual report to you and thank the Infection Control Team for their excellent leadership of this and all the Trust for their continued focus that they are giving to this important area Pippa Barber Executive Director of Nursing and Governance (DIPC)
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2. EXECUTIVE SUMMARY
The Annual Report of the Director of Infection Prevention and Control provides information on the progress and achievements of the Infection Prevention Control Team throughout the period of 2014/15. The Corporate Nursing Team in 2014 developed a Physical Health Team which now incorporates infection prevention and control. The report continues to give assurance of the continual commitment to the prevention and control of infection within all services to achieve positive outcomes. This report summarises the infection control activities carried out in the Kent and Medway NHS & Social Care Partnership Trust during 2014 – 2015. The Trust continues to promote infection prevention and control as the heart of good management and clinical practice, and is committed to ensuring that appropriate resources are allocated for effective protection of patients, their relatives, staff and members of the public. In this regard, emphasis is given to the prevention of healthcare associated infection (HCAI) and the improvement of cleanliness in all our in-patient wards and community settings. This annual report has been written to provide information about our current progress on infection prevention and control and our future direction for the Trust. This information is primarily intended for our internal organisation, external partners, patients and their carers, but may also be of interest to members of the public in general.
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3. INTRODUCTION
Kent and Medway NHS & Social Care Trust has a pro-active infection prevention and control team that is very clear on the actions necessary to deliver and maintain patient safety. Equally, it is recognised that infection prevention and control is the responsibility of every member of staff and must remain a high priority for all to ensure the best outcome for patients. The Trust has a zero tolerance to avoidable infections and a collective responsibility which places a duty on all staff to minimise the risk of infection at all times. The annual programme of work for 2014/2015 focused on ensuring ongoing compliance with the Health and Social Care Act 2008 This report provides assurance from the DIPC that the Trust has a robust, effective and proactive infection prevention and control programme in place that demonstrates compliance with the Health and Social Care Act 2008. The Trust is formally registered with the Care Quality Commission (CQC) and declared as
compliant with the Health and Social Care Act 2008. In December 2010, a revised code of practice was introduced for the prevention and control of health care associated infections (HCAI); The Health Act (2008), Code of Practice on the Prevention and Control of Infections and Related Guidance. The code of practice is also referred to as the Hygiene Code and is regulated by the Care Quality Commission. The Trust remains committed to ensuring that patient safety is at the forefront of everything we do and promotes infection prevention and control as the heart of good management and clinical practice. The Trust is committed to ensuring that appropriate resources are allocated for effective protection of patients, their relatives, staff and members of the public. Infection prevention and control continues to be essential in ensuring that people who use health and social care services receive safe, effective, well-led, responsive care. Effective prevention and control must, and is part of everyday practice and has to be applied consistently by everyone. Infection Prevention and control is everyone’s business . The key documents and legislation including that the Organisation adheres to are:
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
Care Quality Commission (Registration) Regulations 2009.
Care Quality Commission Essential Standards of Quality and Safety 2009.
Code of Practice for health and adult social care on the prevention and control of infections
and related guidance (2010) - Outcome 8 of Essential Standards of Quality and Safety 2009.
All relevant NHS / DH / NPSA Guidance.
All relevant expert guidance / evidence-based practice.
Evolving clinical practice, expanding services, emerging infections, antimicrobial resistance and an increase in vulnerable populations present new challenges for which a constant review of policies and procedures is essential.
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4. STRUCTURE, ACCOUNTABILITY AND ASSURANCE
The structure for the Management of the Infection Prevention and Control Service is in compliance with Hygiene code 2008 The Chief Executive is accountable for the provision of a safe patient environment, Including the prevention and control of healthcare associated infection. The Director of Infection Prevention and Control (DIPC) The DIPC has lead responsibility for the prevention and control of healthcare associated infection (HCAI) and is accountable for this to the Chief Executive. The Trust wide Infection Control Group meets bi monthly and draws clinical members of staff from all Service lines. It is the key forum for the discussion; development and planning of all activities by which the Trust Board both receives and provides assurance those systems are in place for the prevention of HCAI. The Infection Control Team. This team comprises of the DIPC, Deputy DIPC. In 2014 the formulation of a physical health team commenced and this now incorporate IP&C The Senior Infection Control Nurse who report directly to the physical health lead nurse, carries out the day-to-day management of the Infection Control Service. Microbiology Services. The processing of clinical specimens is carried out via the microbiology departments within the 4 Acute hospitals within Kent through service level agreements. (SLA)
Donna Eldridge Deputy Director of
Nursing (Deputy DIPC)
Angela McNab Chief Executive
Pippa Barber Director of Nursing
& Governance (DIPC)
Alison Worsfold
Physical Health Lead Nurse
Rod Harford-Rothwell
Senior Infection Control Nurse
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5. REPORTING MECHANISIMS
In 2014/15 the DIPC reports to the board on a bi-monthly basis. These reports are exception reports and risk incident summaries. Data surveillance for the previous month is also reported on. Data surveillance of all suspected or confirmed infections are emailed through to the infection control team from all services and this is monitored through the Trust wide Infection Prevention and Control group. The day to day infection control issues are dealt with in the first instance by the Senior Infection Control Nurse with support and advice from the Physical Health Lead Nurse and Deputy DIPC. The members of the Infection Control Team provide infection control expertise including results of surveillance, audit and alert organism reporting to a variety of groups across the organisation. The senior infection control nurse has continued to provide a named infection control link to senior staff within the services lines.
6. ASSURANCE FRAMEWORK
The Health and Social Care Act’s (2008) Code of Practice for health and adult social care on the prevention and control of infections and related guidance (also known as the Hygiene Code) was revised and came into force in April 2010.
The Kent and Medway NHS and Social Care Partnership Trust formulated an assurance framework which ensures that all relevant actions are being taken by our Trust to ensure compliance with the 10 criteria identified in the Hygiene Code. The Infection Prevention and Control Team (IP & C) produces the assurance framework which provides our Trust with a simple but comprehensive method for the effective and focused management of the principal risks to meeting our objectives. It also provides a structure for the evidence to support the statement on internal control. (Appendix A)
7. POLICIES
The following policies were updated during 2014-2015 and are available to staff on the staff intranet and in paper format kept on the wards / units:
Acintobacter ANTT – Aspetic Non-Touch Technique Blood Borne Virus Management – (New 2015) Books, Toys, Games & Magazines Cleaning Policy (New 2015) Clostridium difficile Management Policy Hand Hygiene Human Infestation Policy [formerly Scabies & Headlice Policy] (New 2015) Isolation Nursing Policy Mattress, Cushions, Duvet & Pillow Policy (Revised) MRSA Screening Taking Specimens Trust-wide Infection Prevention & Control Policy Tuberculosis Vancomycin Resistant Enterococci /.Glycopeptide Resistant Enterococci Varicella Zoster Virus (VZV) Viral Haemorrhagic Fever / Ebola Ward Closure Policy
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During this time the IP&C Team revised all patient information leaflets to keep them current and up to date with best practice guidelines also The Infection Prevention and Control Aide Memoir leaflet was revised during 2014-2015.
The policies are reviewed and updated in line with current legislation and guidance.
8. CLINICAL AUDIT AND EFFECTIVENESS
There were 3 audits undertaken and described in this report:
1. Trust wide Infection Prevention and Control Audit (to include the unannounced visits) 2. Hand Hygiene Audit 3. Mattress Audit
TRUST WIDE INFECTION PREVENTION & CONTROL AUDIT (incorporating the unannounced visits)
Reducing nosocomial healthcare associated Infections is of major national and local concern for the health service in order to help reduce needless harm to service users and reduce the impact HCAI’s can have on the trust. The Kent and Medway NHS & Social Care Partnership Trust (KMPT) are required to produce an audit to develop and implement plans for reducing Healthcare Associated Infection (HCAI), including Methicillin Resistant Staphylococcus Aureus (MRSA), Clostridium difficile (C.diff) and other significant infections. Last year the data collection audit tool used was SNAP - software made available via a web link which could be accessed via the KMPT Staff Zone website. However due to the time element involved it was agreed at the Trust Wide Infection Prevention and Control Committee for the Senior Infection Control Nurses (SICN) to carry out this audit. This had a 2 fold effect:
1. To reduce the burden of audits on the ward teams 2. To increase inter-rata reliability by having an infection control practitioner undertaking and reporting
the data captured. The audit tool used was adapted from a previous version that had been updated and revised. The environmental elements (Kitchens areas) are audited by the Quality and Performance Teams by Kent & Medway Facilities on behalf of the trust and undertaken separately thus avoiding duplication. Both auditors discussed the marking of the elements assessed to ensure that we capture as much information with regards to meeting the HSCA’s 10 elements.. It was agreed at the Trust Wide Infection Control Group (ICG) that all in patient units including the recovery service would be audited, an audit cycle was developed and if wards scored 90% or higher at every 6 months, 3 monthly if below 90% and monthly if 60% or lower through the unannounced visits structure. Once an audit is undertaken each ward / community team is provided with a copy of the audit tool, action plan with a time frame to complete and return the action plan to complete the audit process. RESULTS (General)
In-Patient:
From the audits conducted between April 2014 –March 2015 the trust has seen a significant improvement in the wards compliance from their initial visits to any subsequent revisits, Issues around sharps management, decontamination, policies and signage have been addressed both at the time of the audit and later during infection control training sessions.
Community:
The biggest challenges for community teams were around the safe carriage of sharps and waste products when travelling in the car to visit clients in their own homes. The IP&C team saw this as a significant risk to the worker and this process was looked at jointly with the Dangerous Goods Safety Officer (DGSO) to
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check compliance with the law on their carriage and current guidance. Following this study, changes were made to ensure that community teams procure the right container to meet UN 3373 and UN 3291 through the use of the red safety box was rolled out to contain these products to meet the carriage of dangerous goods standards. There had also been inconsistencies of waste disposal at some sites due to the wrong sharps products placed in certain containers to dispose of their waste items.
AUDIT DATA RESULTS COMPARISON BY SERVICE LINE (YEAR END)
ACUTE SERVICES
OLDER ADULTS
FORENSIC & SPECIALIST SERVICES
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REHABILITATION SERVICES
COMMUNITY SERVICES Community Teams: The trusts community teams saw a large reorganisation of their services with some units moving to new larger premises and others into hubs to enable a more efficient use of these teams for the communities that they serve. Thirteen community audits have been carried out during this reporting period. Community teams are audited annually, this year saw a significant improvement of the units audited and 2 units fell below the 90% standard ensuring compliance with the Health & Social Care Act, Eleven teams scored 90% or higher during this period. This is a fantastic effort compared to last years report and shows that infection control is being successfully implemented within these teams.
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The biggest challenges for the community teams were around the safe carriage of sharps and waste products when travelling in the car to visit clients in their own homes. This process was looked at jointly with the IP&C team and the Dangerous Goods Safety Officer (DGSO) officer to check compliance with the law on their carriage and current guidance. Following this study changes were made to ensure that community teams procure the right container to meet UN 3373 and UN 3291 Carriage of dangerous goods standards. There had also been inconsistencies in waste disposal of sharps using the wrong coloured containers. Alcohol hand rubs were in abundance and still in use in addition to issues highlighted around the cleaning of the buildings and clinical areas.
Of the two units that failed to meet the 90% standard they were re-audited within 3 months to assure the organisation of the teams compliance. There were no teams scoring less than 70%..
SUMMARY The trust-wide unannounced visits form part of the overall Infection Prevention and Control Audit strategy and have proved enormously beneficial to ensure that all in-patient units and community teams comply with the Trust’s policies and procedures and to meet the 10 elements of the HSCA 2008. Where inconsistencies or areas that have failed to meet these standards were discovered, these were addressed quickly and action plans devised and sent to the ward / unit managers, service leads and associate directors to address any issues to ensure that they are remedied quickly and reducing risk to service users and the organisation. There was an additional benefit in these visits by providing face to face training including staff of all disciplines participating in the hand hygiene exercise using the ultra violet hand box as a tool to demonstrate both good and poor techniques in hand hygiene. 305 staff participated in this exercise. In-line with all NHS Organisations were are obliged to produce, monitor and manage any policies devised to help to protect our service users from harm acting as a guideline for safe practice, all policies are reviewed regularly and also when any new guidance is published nationally, This reporting period saw many of our policies reviewed and these are now in place. Every ward, unit and community team that was inspected had demonstrated good practice had this was re-affirmed in their individual audit report. The unannounced inspections being a valuable resource will continue throughout the year.
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HAND HYGIENE AUDIT The trust regularly undertakes a hand hygiene audit across all inpatient services conducted by the infection control link practitioners it’s aim is to ensure that effective hand hygiene remains a solid and essential basis for the attainment of patient safety, contributing to a significant and measurable reduction in healthcare associated infections (HCAI’s).
From 2013, all older persons in-patient wards are expected to complete monthly observational hand hygiene audits. Forensic, Acute and Community Recovery Units complete the observational audit annually. The results of these audits are returned to the infection control team who compile the data into an excel spreadsheet and to ensure that all in-patient sites had participated.
Best Practice Identified: Certificates are generated upon completion of monthly / annual hand hygiene audit and displayed in the wards / units infection control notice board or at the entrance to the unit n recognition of good practice and achievement.
The above table shows that full compliance was met across all audited areas when the hand hygiene audits were undertaken. This is the third successive year that improvements have been achieved. Scoring: The audit scores are RAG rated (Red, Amber, Green) determined by their %.
Red under 70% Amber under 90% Green 90% and above
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Figure 1: Acute Service Line
Hand hygiene audit compliance across the Acute Service Line is reported as 100% between April 2014 and March 2015. These audits are conducted by the Infection control link practitioner conducting a 20 minute observational audit on an annual basis. Figure 2: Older Persons / Specialist Services
The Older Adult service line is required to undertake a monthly hand observational hand hygiene audit as agreed with our commissioners, these audits are conducted by the link nurse for each clinical area. The 2014 – 2015 reporting period saw all units report full compliance with this guidance.
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Figure 3: Forensic Service Line
The Forensic & Specialist service line hand hygiene audits are undertaken by their link nurses and are conducted on an annual basis and once completed forwarded to the Infection Control team. The total compliance for the Forensic service line is reported at 100% using the Lewisham hand hygiene tool. Figure 4: Community Recovery Service Line
These audits are conducted by the link nurse for each unit and they are responsible for carrying out these audits on an annual basis. All departments reported full compliance when using the Lewisham hand hygiene tool.
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URINARY TRACT INFECTION AUDIT
The aim of this audit was to examine the amount of urinary tract infections being reported across the trust during April 2014 and March 2015 looking at the type of infection and whether a indwelling urinary device was present., also to see if there were any reasons or common trends that would explain the recent increase seen in reporting. This audit identified that the trust saw a decrease in the numbers of urinary tract infections (UTI’s) being reported with 99 cases reported over the year 2014-2015 against 193 for the 2013-2014 period.
Urinary tract infections are one of the most common type of infections reported in patients which can have a detrimental affect on their physical health as well as their mental health state. They result in prolonged hospital stays and increased costs for healthcare providers. Urine infections can affect a patients personality and behaviour and go on to cause some acute and challenging traits to manifest. Urine infections can be caused by and through poor hygiene practices, poor hydration resulting in not keeping the urinary tract healthy or also due to indwelling devices used to monitor renal function of a patient. Indwelling devices (Catheters) are a particular risk as they need to be monitored by healthcare professionals daily to make sure the device does not become contaminated or encrusted and that they are used for a specific reason and for the shortest time.
“A catheter is a ladder to the bladder” For the purpose of increased surveillance the UTI audit looked at a period 3 months snapshot audit to see how this affects the service lines and the type of infections being reported.
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This audit period highlighted that the Older adult service line had 1 E-Coli (ESBL) urine infections that required specialist treatment due to their resistant nature to some antibiotics. The greatest number of urinary tract infections was seen within the older person service line over the financial year. This is due in part to this group of service users which may already suffer with reduced immunity and long term urinary tract problems which can and may be long standing, this makes them particularly harder to treat with the service users diminishing mental health state. All these identified urinary tract infections across all service lines were treated with antibiotics which are monitored by the SICN and the antimicrobial pharmacist, antibiotics can pose a problem if these treatments are not managed effectively. All the reported infections were closely monitored by the infection control team to ensure that the treatment they were offered was appropriate and of the shortest duration to prevent any antibiotic associated diarrhoea. If a urinary tract infection is suspected, most UTI’s are treated with a broad spectrum antibiotic for the shortest duration which is used prophylactically until we know what organism is causing the infection. Where possible a urine sample is collected and sent to the laboratory for analysis in an attempt to isolate the organism responsible, the laboratory will inform the clinician to change treatments to be more specific to that infection isolated. Service users affected with organisms that are harder to treat have their antibiotic therapy adjusted by the microbiologist to ensure that the correct antibiotic was used to treat that coliform. The reporting of urinary tract infections by clinical areas showed that only 70% of these infections had a urine specimen sent for testing to confirm a genuine infection, although the service user was treated prophylactically and then treatment was reviewed at a later date. The data captured by the wards using the reporting template and mechanisms currently in-place across the trust show a greater awareness by staff through correctly assessing the problem and earlier reporting which is enabling service users to be correctly treated to prevent long term harm and reducing suffering. The data also shows that the majority of antibiotic treatments were appropriate in treating these infections with only a few requiring further treatment and monitoring. Findings: This report has shown a decrease on last years findings, although the amount of urinary tract infections for 2014-2015 remain steady and that treatment is being commenced earlier due to better recognition and monitoring . All antibiotic usage is being closely monitored to make sure that the service user is being treated effectively for the shortest duration possible with the correct treatment to prevent antibiotic associated diarrhoea. There are often seasonal variations that occur but these are short in duration and it is recommended that we will revisit this audit again to obtain further assurance. From May 2013 the Trust Development Authority (TDA) has required the Trust to record, capture and report all catheter associated urinary tract infections (CAUTI’s). We have the necessary mechanisms currently in-place to capture this data. The only areas that regularly use indwelling urinary devices (Catheters) are the Older Adult service line and the Knole Centre (WKNRU). TRUST WIDE MATTRESS AUDIT Hospital mattresses are often used by more than one service user these can denature quickly from their excessive use by facecal staining, pin-holes or broken seals. Poor maintenance of mattresses and their covers may lead to contamination or inner surfaces of the mattress covers. Mattress covers can become damaged at any time during use or storage, for example from: needle stick; strike-through; damage from sharp objects; abrasion during handling, transport or movement; inappropriate cleaning and decontamination procedures. The damage can encourage the growth of micro-organisms, which are a
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potential cause of cross infection. If mattresses with non-removable covers are in use it is impossible to check the level of contamination on the inside. All inpatient sites were issued with instructions on the Mount Vernon Criteria for Mattress Auditing. This followed the MHRA Notification on the correct process. The results of the 2014 /15 Trust wide mattress audit shows that a total of 423 mattresses audited within all inpatient wards or units across all service lines. 12 mattresses failed due to broken or damaged surfaces and have been replaced 411 mattresses passed the audit. The trust has embarked on upgrading the mattresses in use across the trust and this has helped to achieve this figure.
o Acute service line 4 out of 177 mattresses had failed the audit, This was a reduction on the same
period last year.
o Older adult service line 4 out of 162 mattresses failed inspection
o Forensic and specialist service line audited 138 mattresses and 2 failed
o For the Community & Recovery service line, 67 mattresses were audited and 2 failed.
The results have conclusively demonstrated the benefit of auditing the mattresses with KMPT. The report will be shared with the Health and Safety Group to look at the types of mattresses procured within the Trust and of their effectiveness. This audit will continue on an annual basis.
9. ANTIMICROBIAL PRESCRIBING AND MANAGEMENT
Effective antimicrobial stewardship within hospitals and community settings makes an important contribution to the control and prevention of Clostridium difficile (C.diff), associated diarrhoea and other health care associated infections. The Trusts Antimicrobial Prescribing and Management Policy has been devised to provide a robust structure and guidance to all trust staff on the safe use these medicines across all KMPT’s inpatient and community settings. This policy is available for all staff to access both in paper form and on the trust intranet site. Monitoring compliance and effectiveness of this document includes the need for inpatient units to submit antibiotic data to the Infection Prevention & Control Team (IP&C) when any antibiotic is prescribed. This information is collated onto a database and any concerns regarding antimicrobial prescribing is addressed between the IP & C Team, ward staff, the prescribing doctor and pharmacy staff.
10. TRAINING AND EDUCATION
Training remains high priority on the IP & C Team’s agenda, providing face to face training for staff or producing the training packages used for core training or e-learning. During the period from the 1st of April 2014 to the 31st of March 2015 a total of 1946 staff were trained in infection prevention and control through a variety of training methods which include:
e-Learning packages.
Face to face taught sessions
Ad-hoc drop in
Link Nurse training & development
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Link Nurse 3 monthly updates
Light box hand hygiene training for in-patient & community teams
Student nurse Infection Control Training
Course
% Target
to Achieve
Overall Trust
Corporate Services
Forensic &
Addictions SL
Older People & Specialist
SL
Community Recovery
SL Acute SL
Data to 26
Feb 14 Data to 26
Feb 14 Data to 26
Feb 14 Data to 26
Feb 14 Data to 26
Feb 14 Data to 26
Feb 14
2 Year Update
Infection Control/Hand Hygiene
2 Yearly 85% 85% 76% 97% 88% 81% 79%
3 Year Update
Infection Control/Hand Hygiene
3 Yearly 85% 90% N/A 96% 88% 90% 88%
Once Only
Infection, Prevention & Control
Once 85% 90% 95% 97% N/A 90% N/A
11. LINK NURSE – PRACTITIONERS
All wards / in patient units and community teams have an identified link nurse workers in place working in partnership with the Senior Infection Control nurse to provide infection prevention and control support to their clinical areas. They undertake a one full day intensive link nurse training programme facilitated by the SICN, this enables the link practitioner to undertake training of staff within their own clinical areas. This session provides them with the skills required to facilitate this role successfully and they are continually updated through link nurse meetings and adhoc communication. Link nurse meetings are held on a quarterly basis across the organisation. They act as a communication tool and to impart information from Board to Ward and also offer network opportunities for staff. The sessions look at the role of the link nurse, the focus on reducing HCAI’s within the trust, the importance of good effective hand hygiene practices, the different organisms that affect the clinical environments and how we can manage the risks they pose, a journal club which link nurses are encouraged to advance and develop their own understanding of infection control as well as engage our service users in the fight against infection. Outside facilitators are also provided to advance their scope of practice and their understanding.
12. NEEDLESTICK / SHARPS INJURIES
Needlestick injuries occur when a needle or other sharp implement penetrates the skin. This is called a percutaneous injury. If the needle or sharp instrument is contaminated with blood or other bodily fluids, there is the potential risk of transmission of infection, and when this occurs in a work context, the term occupational exposure (to blood, body fluid or blood-borne infection) is used. Staff experiencing this type of injury risk acquiring Hepatitis B, Hepatitis C and Human immunodeficiency virus (HIV). To minimise this risk
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to staff and patients KMPT have been using Retractable (Sharp safe) syringes across all in-patient and community teams. KMPT was ahead of the curve and introduced these across the trust in 2011. Legislation has made this mandatory for healthcare providers from May 2013. Since the introduction of these devices there has been a significant reduction in these type of injuries reported. The trust is continually trying to reduce the risk of injury to staff carrying out their duties and the infection control team is constantly reviewing the use of sharp devices to meet the need of the service.
There have been 23 reported cases of sharps injury for this year which is an increase on the previous year. 10 incidents were related to the giving of insulin although insulin can be given with retractable needles. During resuscitation training session a sharps injury was obtained as the instructor thought the epi-pen was a training device but in-fact was a live version and punctured her finger. This injury was investigated and reported, no serious injury to instructor reported. This incident is being reviewed by the Health and Safety executive. The physical health team will be reviewing the use of retractable needles to ensure that a reduction in injuries occur throughout 2015.16
13. OUTBREAKS / PERIODS OF INCREASED INCIDENCE
OUTBREAKS The amount of reported outbreaks for 2014 – 2015 was significantly lower than in previous years. This reporting period saw 3 outbreaks due to diarrhoea and vomiting and 1 period of increased incidence. In 2013- 2014 6 outbreaks were reported and in 2012 – 2013 there were 10. All outbreaks affecting the trust are reported directly to the SICN via the infection control email address or by telephone, once all facts are established the SICN visits the unit to ensure that all appropriate infection control measures are in-place. The units affected were::
Sevenscore Ward (Thanet) May 2014, 10 patients and 6 staff affected, closed for 15 days. Tulip House (Maidstone) July 2014, 4 patients affected, unit closed for 4 days. Ruby Ward (Medway) July 2014, 4 patients affected, closed for 4 days. Emerald Ward (Medway) July 2014, 3 patients affected, ward closed for 6 days.
Tulip House is reported as a period of increased incidence with no reported infection but ward closed for observation due to nature of the clients it houses.
When an outbreak of infection has been declared the SICN will undertake an Route Cause Analysis or Post Exposure Review to establish a cause and identify any learning from such events that can be shared across the trust in effort to reduce the impact of this infectious illness occurring in the future. CLOSTRIDIUM DIFFICILE TOXIN POSITIVE INFECTION There have been no reported Clostridium difficile toxin positive cases for this current year. This is the second year of zero reporting, the last case reported was in September 2012. OTHER INFECTIONS REPORTED As part of the trusts mandatory reporting of MRSA and Clostridium difficle infections all wards also reported cases of 18 dental infections, 10 wounds (including self harming), 4 episodes of scabies infestation, 18 cases of ear, nose or throat infections, 5 episodes of head lice, 7 MRSA colonisations, 51 chest infections, 10 cases of cellulitus, and 109 urine infections (including 1 ESBL Infection).
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14. MRSA SCREENING
The Department of Health (DH) requires all NHS Trusts to record MRSA screening data for elective and emergency admissions. Within Mental Health, we do not have elective patients, therefore the DH had identified incidents of greater clinical risk. Therefore the screening criteria within KMPT is as follows: service users who are admitted to mental health wards or units having had surgery or any surgical
procedures any service user who was transferred from an Acute Trust drug users that use intravenous drugs service users who self harm service users with chronic wounds, e.g. leg ulcers or have a catheter or any other indwelling device The Knole Centre (WKNRU) in Sevenoaks was identified and deemed suitable to meet the criteria for emergency admissions, and therefore every patient will be screened on admission to the unit. With adherence to the MRSA screening policy there had been a significant reduction of MRSA colonised patients on our units. There were 7 cases of patients colonised with MRSA during this reporting year. This is compared against last years figure of 10 (2014-15) and 12 in (2013-2014).. There have been no reported cases of MRSA bacteraemia (MRSA bloodstream infection) during this last year. The last case reported was October 2011.
15. DECONTAMINATION
The IP & C Team have been working closely with the Medical Device Manager to ensure that sufficient guidance was available to staff on the safe methods of decontamination for medical devices. This is to protect all staff and service users from the transmission of micro-organisms from medical devices, associated consumables and materials used in the physical assessment, treatment, diagnosis and care of our service users. The following measures are in place: To ensure that all mattresses are fit for purpose and do not present a cross contamination risk, an
annual Trust wide mattress audit will continue, all wards are now using the Fist Test to ensure patency. Single patient use items are being used and all ward teams are questioned on audit the symbol for
single use items and ensures that these items are being used, e.g. nail clippers, disposable slings and scissors.
Disposable items and single use items are promoted and recommended e.g. bowls (that are macerable), medicine pots and disposable tourniquets.
Decontamination of rooms/wards during an outbreak or post outbreak with a chlorine based solution is used for environmental cleaning to prevent the contamination of hard surfaces, which in turn reduces the risk of cross infection. Soft furnishings such as curtains are replaced with clean ones.
Working closely with the Housekeeping teams across the trust to ensure that all IC measures are adopted and utilised to help in the fight against infection or outbreak.
The schedule for on-going cleaning audits is as follows;
Non-patient sites that score 80% and above are audited on a twice yearly basis.
Non-patient sites that score below 80% are audited on a quarterly basis.
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Outpatient sites that score below 90% will continue to be audited on a Quarterly basis
Outpatient sites that score 90% and above will be audited on a 4 monthly basis.
In-patient Areas that score below 90% will be audited on a bi (2) monthly basis.
In-patient areas that score 90% and above continue to be audited on a Quarterly basis When a site falls below the proposed standard it must obtain one consistent pass marks at the higher level before it reverts back to the proposed schedule. The results are discussed at the trust Infection prevention and control Group meetings bi-monthly.
16. COMMODES
There are eleven wards / units across the Trust that has and uses commodes (The Older Persons Service line). All commodes use disposable macerable liners to reduce the risk of infection, All had a macerator in clean working order. Eight of the eleven units had commodes that were clean and in good working order. Where commodes were found to be in a poor condition these were reported and replaced with newer versions. Areas identified that did not attain 100% were addressed with the staff concerned during the visits. These wards monitor their commode cleanliness on a weekly basis to ensure compliance.
17. SEASONAL INFLUENZA CAMPAIGN
This year saw the trust build on it’s success and increase in the number of front line staff receiving the seasonal flu vaccine. Last year also saw the Department of Health introduce targets for providers to achieve and set a target of 75% uptake for frontline staff to be vaccinated. The programme began in October 2014 through to March 2015. The flu fighting team set dates and arranged venues across the trust to enable staff to access the vaccine as close to their place of work as possible. This helped to increase the trusts uptake from 41% in 2013 -2014 to 42% this year, in 2012 -2013 the trust only managed 25% A total of 1098 front line staff were vaccinated during the campaign. A debrief following this campaign has commenced to learn lessons and facilitate a more successful campaign in 2015-16.
18. Conclusion
Within 2014/15, the Infection Prevention and Control Team maintained and improved the standards of care for our patients in relation to infections. This has been achieved by working in partnership with internal service lines other external organisations, auditing practice that results in changes to clinical practice and ensuring that all staff are trained to a high standard.
It is to be acknowledge that the Senior Infection Control Nurse has maintained the highest of standards for infection control ensuring that all infections are responded to quickly which has led to a reduction in outbreaks from previous year
22
KMPT HYGIENE CODE COMPLIANCE 2014/15
Development Plan for Infection Prevention and Control to meet the Health and Social Care Act’s (2008) Code of Practice for the
NHS on the prevention and control of healthcare associated infections and related guidance
Compliance Criterion 1 – Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and
consider how susceptible service users are and any risks that their environment and others may pose to them.
1.1 Appropriate
management and
monitoring arrangements
should ensure that:
Self assessment Description for compliance Actions responsibility Progress
A board level agreement
outlining the boards
collective responsibility
for minimising the risk of
infections and the general
means by which it
prevents and controls such
risks
Infection Prevention and Control
(IP & C) policy in place.
Trust Wide infection Prevention
and Control Group in place.
Bi-Monthly reports to the Board.
Demonstrates sign up by the board of
directors. The report is submitted bi-
monthly
Reports to Board which
incorporate minutes from the
Trust IP & C Committee
CEO
Executive Director of
Nursing and
Governance/DIPC
The designation of a DIPC
who is accountable
directly to the CEO and
the board
Appointment of the Executive
Director of Nursing and
Governance/DIPC
DIPC in place job description reflects
roles and responsibility.
None Required CEO
The mechanism by which the board intends to ensure that sufficient resources are available to secure the effective prevention and control of infection.
Bi-Monthly Board reports Within the board minutes sign up to
resources
None Required Executive Director of
Nursing and
Governance/DIPC
Ensuring that relevant
staff, contractors and other
persons receive suitable
training and information
Face to face training is provided
for staff, as is Corporate
induction and e-learning for
clinical and non clinical staff.
Training records
All contractors have a letter.
Learning and Development
Department to monitor the
number of staff undertaking
the training
Learning and
Development Dept
Executive Director of
23
and supervision in,
measures required to
prevent and control risks
of infection
Record of staff attendance to
training is kept by the L & D
department.
Training Policy identifies levels
of training needed for staff.
Link nurses meetings for the
Trust
Visitors Ward closure signs
Lead nurses to ensure
attendance of the link nurse
meetings
Nursing and
Governance/DIPC
Deputy Director of
Nursing /deputy DIPC
Lead Nurses
Service Managers/Service
Managers/Modern
Matrons.
Head of Facilities
A programme of audit to
ensure key policies and
practice are being
implemented
appropriately
IP & C Audits are carried out in
all service areas annually.
Monthly Hand Hygiene Audits
Annual Trust wide Mattress
audits
Annual audit of Transfer of Care
Infection Control
Documentation.
PLACE visits
Unannounced Visits (now known
as IP & C compliance to policies
and best practice visits)
Demonstrates annual audit of
compliance on a site by site basis
Implement all audit
recommendations
Implement PLACE action
Plans
¼ Cleaning audits
Implement Hand hygiene
Audit Action plans
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing/deputy DIPC
Senior Infection Control
Nurses
Lead Nurses
Service
Managers/Modern
Matrons
Hotel Services
A policy addressing where
relevant the admission
transfer discharge and
movement of patients
between depts. and
between healthcare
facilities
Trust wide Infection Prevention
and control policy
Clearly outlines the process for
checking HCAI’s on transfer of
care/admissions.
Ensure the Transfer check list
is used
Monitor the HCAI transferred
into the Trust from the Acute
Trusts
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing/deputy DIPC
IP & C Team
Service
Managers/Modern
Matrons
Designation of a
decontamination lead
The Deputy Director for
Nursing/Deputy DIPC is the lead
for decontamination
The Deputy DIPC works closely with
the Medical Devices Manager
To be monitored through the
medical devices meeting and
infection prevention and
control meeting minutes
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing/Deputy DIPC
Medical Devices Manager
24
1.2 Risk Assessment
A registered provider should
ensure that it has:
made a suitable and
sufficient assessment of
the risks to the person
receiving care with respect
to prevention and control
of infection
identified the steps that
need to be taken to reduce
or control those risks
recorded findings in
relation to the first two
points;
implemented the steps
identified and put
appropriate methods in
place to monitor the risks
of infection to determine
whether further steps are
needed to reduce or
control infection.
Covered by the audit and service
action plans.
Bi-Monthly board report
Unannounced Infection control
visits- site reports
MRSA management and
Screening Policy
Transfer of Care infection
control documentation form
All suspected/confirmed
infections reported to the IP & C
Team
Demonstrates a rolling programme of 6
monthly unannounced visits to monitor
/ risk assess and ensure compliance
with the Hygiene Code and to provide
support to services
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing/Deputy DIPC
Service
Managers/Modern
Matrons
IP & C Team
1.3 The role of the DIPC
in NHS
provider organisations is to:
be accountable directly to the chief executive and to the board (but not necessarily a member of the board)
be responsible for the organisation’s infection prevention and control team (IPT) or infection control team (ICT)
• oversee local prevention and
control of infection policies and
their implementation;
In DIPC job description
Demonstrates compliance to Hygiene
Code
Minutes of Patient Safety Group
meetings
None required
Executive Director of
Nursing and
Governance/DIPC
25
• be a full member of the ICT and
regularly attend its infection
prevention and control meetings;
• report directly to the NHS board
and, in non-NHS care settings, the
registered provider;
• have the authority to challenge
inappropriate practice and
inappropriate antibiotic prescribing
decisions;
• assess the impact of all existing
and new policies on infections and
make recommendations for change;
• be an integral member of the
organisation’s clinical governance
and patient safety teams and
structures; and
• produce an annual report and
release it publicly as outlined in
Winning ways: working together to
reduce healthcare associated
infection in England.
Chairs Trust wide IP & C group
Antimicrobial Prescribing and
Management Policy
Through trust wide audit
Annual DIPC report produced
Minutes of Trust wide Infection Control
Meetings
Minutes of PCT meetings
Minutes of SHA meetings
Minutes of the local Health Protection
Unit meetings
Minutes of Patient safety and
Governance meetings
1.5 Assurance Framework
regular presentations from
the DIPC and/or the ICT
to the board. These should
include a trend analysis
for infections and
compliance with audit
programmes;
quarterly reporting to the
NHS board or registered
provider by clinical
directors and matrons
(including nurses who do
not hold the specific title
of ‘matron’ but who
operate at a similar level
of seniority and who have
Assurance Framework in place
RCA’s and audits performed
Outbreak Management Team
IP & C Team to support and
advise ward on actions to take
Assurance Framework monitors
compliance to the Hygiene Code. It is
monitored by the IP & C Team and the
Trust wide Infection Control group.
Service Managers/Modern Matrons
monitor and update this through the
modern matron forums.
The IP&C team provide bi- reports to
the board that is shared with the
Matrons at the 6 weekly meetings that
is a 2 way sharing of information
process demonstrating that infection
prevention and control are an integral
part of quality assurance
To be monitored through the
board, IC meetings, Service
Managers/Modern Matrons
Meetings
Link nurse Meetings
Service Managers to produce
a quarterly report to the
Board.
CEO
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy DIPC
IP & C Team
Service
Managers/Modern
Matrons
26
control over similar
aspects of the patient or
the patient’s
environment);
a review of statistics on
incidence of alert
organisms (for example,
but not limited to,
meticillin-resistant
Staphylococcus aureus
(MRSA) and Clostridium
difficile) and conditions,
outbreaks and serious
untoward incidents
evidence of appropriate
action taken to deal with
occurrences of infection
including, where
applicable, root cause
analysis; and
an audit programme to
ensure that policies have
been implemented;
SI meetings / minutes of
meetings
IP&C investigate RCA and
report findings to Trustwide
Infection Group who cascade any
learning throughout the Trust and
the SI Risk Manager.
1.7 The infection prevention and
control programme should:
• set objectives that meet the needs of the organisation and ensure the safety of service users;
• identify priorities for action; • provide evidence that relevant policies have been implemented to reduce infections; and • if appropriate, report progress against the objectives of the programme in the DIPC’s annual report or the IPC Lead’s annual statement.
Trust Wide Infection Prevention
and Control group
Infection Control Link Nurse
Meeting minutes
Modern Matron Meetings
Bi-Monthly Board reports
Data Surveillance
Monthly Hand Hygiene
observational audit
MRSA Screening data from the
Nursing Metrics and Infection
database
Monthly training stats
IP & C audits
Demonstrates compliance with Hygiene
Code
Continue with IP & C
programme
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy DIPC
IP & C Team
27
1.8 Infection control
infrastructure
An infection prevention and control
infrastructure should encompass:
• in acute healthcare
settings, for example, an
ICT consisting of an
appropriate mix of both
nursing and consultant
medical expertise (with
specialist training in
infection prevention and
control) and appropriate
administrative and
analytical support,
including adequate
information technology –
the DIPC is a key member
of the ICT;
• in other settings, there will be an
infection control nurse (ICN) or
another designated person who is
responsible for infection prevention
and control matters and has access
to specialist expertise as necessary;
and
• 24-hour access to a nominated
qualified infection control doctor
(ICD) or consultant in health
protection/communicable disease
control. The registered provider
should know how to access this
advice.
Trust Wide Infection Prevention
and Control group
Infection Control Link Nurse
Meeting minutes
Modern Matron Meetings
Bi-Monthly Board reports
Data Surveillance
Access to Consultant/expert at
KHPU 24hours via local acute
hospital switchboard out of
office working hours.
Transfer of Care Audit
Demonstrates surveillance of HCAI’s,
monitoring of database, cleanliness
standards and collaboration with the
Health Protection Agency, Primary
Care Trusts and Acute Trusts and trust
staff
The link nurse meetings Demonstrate a
Trust wide management system for
both dissemination, imparting &
collection of information to clinical
staff and provide support from senior
Infection Control staff
Continue with IP & C
infrastructure
CEO
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy DIPC
IP & C Team
1.9 Movement of patients
There should be evidence of joint
working between staff involved in
the provision of advice relating to
the prevention and control of
infection; those managing bed
allocation; care staff and domestic
staff in planning service user
referrals, admissions, transfers,
Transfer check list
Transfer of Care Infection
Control documentation Audit
Transfer of patients from and to the
Acute Trusts and nursing homes
incorporated within the IP&C policy
To be monitored through the
Service Managers/Modern
Matrons meetings and IP & C
trust wide group
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy DIPC
IP & C Team
28
discharges and movements between
departments; and within and
between health and adult social care
facilities. Where necessary,
ambulance providers, hospitals and
primary care trusts (PCTs) may need
to be involved in such planning
Service
Managers/Modern
Matrons
Ward Managers
1.10 A registered provider must
ensure that it provides suitable and
sufficient information on a service
user’s infection status whenever it
arranges for that person to be moved
from the care of one organisation to
another, or from a service user’s
home, so that any risks to the service
user and others from infection may
be minimised. If appropriate,
providers of a service user’s
transport should be informed of any
infection.
Transfer check list and discharge
letter
Transfer of care infection
Control documentation audit
Transfer of patients from and to the
Acute Trusts and nursing homes
incorporated within the IP&C policy
To be monitored through the
Service Managers/Modern
Matrons meetings and IP & C
trust wide group
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy DIPC
IP & C Team
Service anagers/Modern
Matrons
Ward Managers
Compliance Criterion 2 – Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and
control of infections
2.1 With a view to minimising the
risk of infection, a registered
provider should normally ensure
that:
Self assessment Description for compliance Actions responsibility Progress
it designates leads for
environmental cleaning and decontamination of equipment used for diagnosis and treatment (a single individual may be designated for both areas)
Hotel Services responsible for
cleaning
Hotel Services managers in
each directorate
Service Managers/Modern
Matrons responsible for
ensuring that ward equipment
is decontaminated
Decontamination of medical
devices identified in the Safe
Management of Medical
Devices policy
Ensures partnership working with hotel
services in cleaning standards for all
buildings
Ensures decontamination issues for
mental health addressed.
Operational Cleaning Policy
Board Reports
Medical Devices Meetings
Hotel Services to monitor cleaning
and contract cleaners
Unannounced Visits
Monitor/report to the IC
committee
Service Managers/Modern
Matrons to ensure that all medical
devices e.g. commodes/beds/hoists
are decontaminated in accordance
with manufacturer’s guidance.
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP&C Team
Service
Managers/Modern
Matrons
rvices
Medical Devices
Manager
29
the designated lead for
cleaning involves
directors of nursing,
matrons and the ICT or
persons of similar
standing in all aspects of
cleaning services, from
contract negotiation and
service planning to
delivery at ward and
clinical level. In other
settings, the designated
lead for cleaning will
need to access
appropriate advice on all
aspects of cleaning
services
All aspects of cleaning services are discussed in the Trust wide Infection Prevention & Control Group in which the Deputy Director of Nursing, the Infection Prevention & Control Team and Service Managers/Modern Matrons attend.
Ensures partnership working with hotel
services in cleaning standards for all
buildings
Continue to involve Deputy
Director of Nursing, Service
Managers/Modern Matrons and
the IP & C Team in all aspects of
cleaning services
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Hotel Services
It has policies for the
environment that make
provision for liaison
between the members of
the ICT and the persons
with overall
responsibility for
facilities management;
PLACE assessment undertaken
by facilities, clinical staff and
IC staff.
Hotel Services attend all IP &
C meetings at Trust and local
level
Attendance to IC Link
meetings
Overarching policy re link with
IP & C team
Hotel Services and Facilities as members
of the I.C. committee
Continue with PLACE
assessments
Monitor attendance
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Hotel Services
in healthcare, matrons or
persons of a similar
standing have personal
responsibility and
accountability for
delivering a safe and
clean care environment
Service Managers/Modern
Matrons are aware of
responsibilities and
accountabilities (Job
Description’s and IP & C
policy)
Nurse in charge of shift is
aware of responsibility
regarding cleanliness standards
during their shift
This was included in the Service
Manager’s Job Description’s during the
Service Line restructuring.
To ensure that accountability and
responsibility continues to be
reflected in job descriptions
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
30
Hotel Services
Nurse in Charge of
Shift
Human Resources
Service line directors
The cleaning
arrangements detail the
standards of cleanliness
required in each part of
its premises and that a
schedule of cleaning
frequencies is publicly
available;
Cleaning schedules are openly
displayed on public view on
each ward/unit Trust wide
Demonstrates standards of cleanliness for
each area Trust Wide
Monitored through PLACE
inspection
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Hotel Services
There is adequate
provision of suitable
hand-washing facilities
and water based hand
sanitisers
Individual water based hand
sanitisers for staff available
Hand hygiene notices above all
clinical sinks
Hand Hygiene Audits are now carried out
Trust wide annually to monitor
compliance
Hand Hygiene Link Nurses/ workers on
each ward/unit promote good hand
hygiene techniques and practices for all
staff, patients and visitors
Trust Infection Prevention and Control
training includes the importance of good
hand hygiene techniques and practices.
This is demonstrated by the use of UV
light boxes.
IP & C Training
Hand hygiene Audit
Mobile Sink Unit
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Hotel Services
There are effective
arrangements for the
appropriate
decontamination of
instruments and other
equipment – these
should be incorporated
Hotel Services responsible for
cleaning
Hotel Services managers in
each directorate
Service Managers/Modern
Decontamination of medical devices
identified in the Safe Management of
Medical Devices policy
Service Managers/Modern Matrons
responsible for ensuring that ward
Hotel Services to monitor cleaning
and contract cleaners for cleaning
of beds/hoists/commodes
Monitor/report to the IC
committee
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
31
within appropriate
disinfection and
decontamination
policies;
Matrons responsible for
ensuring that ward equipment
is decontaminated
Board Reports
equipment is decontaminated
The IP & C Team promote the use of
single patient items and single use items
e.g. hoist slings, nail clippers, medicine
pots
Service Managers/Modern
Matrons to ensure that
commodes/beds/hoists are
decontaminated in accordance with
manufacturer’s guidance.
IP&C Team
Service
Managers/Modern
Matrons
Medical Devices
manager
2.2 All parts of the premises in
which it provides healthcare are
suitable for the purpose, kept clean
and maintained in good physical
repair and condition;
Cleanliness reports following
quarterly cleaning audits and
Trust wide monitoring. The
report identifies
PLACE assessment undertaken
by facilities, clinical staff and
IP & C staff.
Infection Prevention and
Control Audit
Hand Hygiene Audit
Demonstrates quarterly cleaning audits
and trust wide monitoring. Also shows
SHA deep cleaning returns
Continue to monitor standards of
cleanliness and maintenance
through the audit process
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP&C Team
Service
Managers/Modern
Matrons
Hotel Services
Estates & Facilities
2.3 Premises and facilities should
be provided in accordance with
best practice guidance. The
development of local policies
should take account of infection
prevention and control advice
given by relevant expert or
advisory bodies or by the ICT, and
this should include provision for
liaison between the members of
any ICT and the persons with
overall responsibility for the
management of the service user’s
environment
Operational Cleaning Policy
Food hygiene policy
Control of Legionella bacteria
in Trust Premises policy and
procedure
Policy for management of
asbestos containing materials in
trust Properties including
asbestos management plan
Uniform and work wear policy
Standard (Universal)
Precautions Policy
Demonstrates compliance with the
Hygiene Code
Update policies when required
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP&C Team
Service
Managers/Modern
Matrons
Hotel Services
Estates & Facilities
32
IP & C policy (infected linen)
And Service Level Agreements
(SLA) with Acute Hospital
Trusts
Standard (Universal)
Precautions Policy.
Linen discussed in IP & C
training
Waste Management policy
Compliance Criterion 3 – Provides suitable accurate information on infections to service users and their visitors
Self assessment Description for compliance Actions responsibility Progress
3.1 Areas relevant to the provision
of such information include:
• general principles on the prevention and control of infection and key aspects of the registered provider’s policy on infection prevention and control, which takes into account the communication needs of the service user;
• the roles and responsibilities of particular individuals such as carers, relatives and advocates in the prevention and control of infection, to support them when visiting service users; • supporting service users’ awareness and involvement in the safe provision of care; • the importance of compliance by visitors with hand hygiene; • the importance of compliance with the registered provider’s
KMPT IP & C website available
to service users/relatives/carers
on the following link
http://www.kmpt.nhs.uk/infectio
ncontrol
Infection Prevention and Control
leaflets are available to patients,
visitors and staff on the
following subjects:
C. diff, MRSA, Noro virus, IP &
C Team, guide for patients and a
guide for visitors about infection
prevention.
Admission, transfer, discharge
and movement of service users is
addressed in the Infection
Prevention and control policy
Signage
Outbreak is defined in the
Infection Prevention and Control
Policy
Demonstrates full compliance with DH
guidance
Ensure that the Admission
,transfer, discharge and movement
of service users form is completed
as per Trust policy
Ensure that signs and information
displayed is current
To be monitored through the
Service Managers/Modern
Matrons meetings and IC trust
wide group
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP&C Team
Service
Managers/Modern
Matrons
Ward Managers
Hotel Services
33
policy on visiting; • reporting failures of hygiene and cleanliness; • explanations of incident/outbreak management.
Ward Closure (Infection Control)
Policy
Isolation (Nursing) Policy
Board minutes are available for
patients, public and staff
Patients and carers are
encouraged to report concerns
regarding infection prevention
and control to staff.
Concerns regarding hygiene and
cleanliness can be reported to the
Ward Manager, Modern Matron
and the Infection Prevention and
Control Team. The IP & C Team
can be contacted via email and/or
phone by patients, visitors or
staff. Whistle blowing policy
can be used
3.2 Information should be developed with local service user representative organisations, which could include Local Involvement Networks (LINks) and Patient Advice and Liaison Services (PALS).
Service user involvement
requested through PALS
managers for IP & C meetings
Links involvement
Demonstrates full compliance with DH
guidance
To be monitored through the
Service Managers/Modern
Matrons meetings and IC trust
wide group
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
34
Compliance Criterion 4 – Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.
Self assessment Description for compliance Actions responsibility Progress
4.1 A registered provider should
ensure that: • accurate information is communicated in an appropriate manner;
• this information facilitates the provision of optimum care, minimising the risk of inappropriate management and further transmission of infection; and • where possible, information accompanies the service user.
IP & C Transfer of care
documentation check list
Outbreaks are communicated to
the KHPU. and adjacent acute
Trust’s DIPC/IP & C Team
Transfer of patients from and to the
Acute Trusts/our Trust and nursing
homes incorporated within the IP&C
policy
Annual Trust wide Transfer of Care
Infection Control Documentation audit
To be monitored through the
Service Managers/Modern
Matrons meetings and IC trust
wide group
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
4.2 Provision of relevant
information across organisational
boundaries is covered by the
regulation requirement ‘Co-
operating with other providers’. Due
attention should be paid to service
user confidentiality as outlined in
national guidance and training
material.
Care Programme Approach
documentation
Outbreaks are communicated to
the KHPU and adjacent acute
Trust’s DIPC/IP & C Team
CPA documentation would record
relevant Infection Control issues and
enable this to be shared with relevant
professionals.
Ward manager via internal records
audits.
Ward
Managers/clinical
staff
IP & C Team
Compliance Criterion 5 – Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the
infection to other people.
Self assessment Description for compliance Actions responsibility Progress
5.1 Registered providers, excluding personal care providers, should ensure that advice is received from suitably informed practitioners and that, if advised, registered providers should inform their local health protection unit of any outbreaks
Outbreaks are communicated to
the KHPU and adjacent acute
Trust’s DIPC/IP & C Team
Reporting flow chart with
contact details are provided to all
teams
Demonstrates Compliance as per
national and local policy
Ensure that IP & C, Hand
Hygiene, MRSA screening and
Uniform and work wear,
antimicrobial prescribing and
management policies, Norovirus
management policy, outbreak
(nursing) policy and Ward Closure
policy reflect any changes in
Ward staff/Ward
Managers
Service Managers
IP & C Team
Deputy Director of
35
or serious incidents relating to infection.
IP & C policy,
Hand Hygiene Policy,
MRSA and Screening policy,
Uniform and Work wear policy,
antimicrobial prescribing and
management policy,
Norovirus management policy
Clostridium difficile policy
Isolation (nursing) Policy
Ward Closure Policy
Policy compliance is monitored
in the annual IP & C and Hand
Hygiene audits.
Bi-Monthly Board reports which
includes infection data
surveillance and training figures
Infection prevention and control
staff training programme
Staff have access to IP & C
Team and IC link nurses Trust
wide.
Unannounced IP & C visits
legislation, standards and
guidance.
Ensure all staff attend IP & C
training and the Learning and
Development Department to
monitor the number of staff
undertaking the training
Monitoring of infection
surveillance data and antibiotic
prescribing data
IP & C Team to update training
programme as required
Nursing / Deputy
DIPC
Executive Director of
Nursing and
Governance/DIPC
5.2 Arrangements to prevent and control infection should demonstrate that responsibility for infection prevention and control is effectively devolved to all groups in the organisation involved in delivering care.
Roles and responsibilities for all
groups identified in the IP and C
policy
Responsibilities in JD’s
Infection prevention and control
staff training programme
IP & C policy, Hand Hygiene
Policy, MRSA and Screening,
Uniform and Work wear policy,
antimicrobial prescribing and
management policy, Ward
Closure policy, Norovirus
Management Policy, Clostridium
difficile policy, Isolation
(Nursing) Policy.
Demonstrates Compliance as per
national and local policy
Ensure that IP & C, Hand
Hygiene, MRSA screening and
Uniform and work wear,
antimicrobial prescribing and
management, ward closure,
Norovirus management and
Clostridium difficile policies
reflect any changes in legislation,
standards and guidance.
Ensure all staff attend IP & C
training and the Learning and
Development Department to
monitor the number of staff
undertaking the training
Monitoring of infection
surveillance data and antibiotic
Ward staff/Ward
Managers
Service Managers
IP & C Team
Deputy Director of
Nursing / Deputy
DIPC
Executive Director of
Nursing and
Governance/DIPC
36
prescribing data
IP & C Team to update training
programme as required
Compliance Criterion 6 – Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.
Self assessment Description for compliance Actions responsibility Progress
6.1 A registered provider should, so
far as is reasonably practicable,
ensure that its staff, contractors and
others involved in the provision of
care co-operate with it, and with
each other, so far as is necessary to
enable the registered provider to
meet its obligations under the Code.
6.2 Infection prevention and control
would need to be included in the job
descriptions and be included in the
induction programme and staff
updates of all employees (including
volunteers). Contractors working in
service user areas would need to be
aware of any issues with regard to
infection prevention and control and
obtain ’permission to work‘.
Confidentiality must be maintained.
6.3 Where staff undertake
procedures, which require skills
such as aseptic technique, staff must
be trained and demonstrate
proficiency before being allowed to
undertake these procedures
independently.
Aseptic Non Touch Technique
Policy
Safe Management of Aspergillus
policy
IP & C responsibilities in all
JD’s via HR and AD’s
The Control of Legionellae
Bacteria in Trust Premises policy
MRSA and Screening policy
Hand Hygiene Policy
Uniform and Work wear policy
Standard (universal) precautions
policy
IP & C information leaflets
Competency framework kept by
Learning and development
department
Demonstrates Compliance as per
national and local policy
For Facilities Department to
continue to send IP & C
information to contractors for them
to sign up to
Monitor adherence to policies
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Facilities Department
HR
Service Line
Directors
37
Compliance Criterion 7 – Provide or secure adequate isolation facilities
Self assessment Description for compliance Actions responsibility Progress
7.1 A healthcare registered
provider delivering in-patient care should ensure that it is able to provide, or secure the provision of, adequate isolation precautions and facilities, as appropriate, sufficient to prevent or minimise the spread of infection. This may include facilities in a day care setting.
The majority of in-patient wards
have single sex accommodation.
Where there are still bays single
rooms are available for isolation
purposes
Ward Closure (Infection Control)
Policy
Norovirus (Outbreak) policy
Clostridium difficile Policy
Isolation (Nursing) Policy
MRSA Management and
screening Policy
Demonstrates Compliance as per
national and local policy
Continue to monitor compliance
through the audit process and IP &
C unannounced visits
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Ward Managers
7.2 Policies should be in place concerning the allocation of patients to isolation facilities, based on local risk assessment. The risk assessment should include consideration of the need for special ventilated isolation facilities. Sufficient staff should be available to care for patients safely.
Ward Closure (Infection Control)
Policy
Norovirus (Outbreak) policy
Clostridium difficile Policy
Isolation (Nursing) Policy
MRSA Management and
screening Policy
Policies are available and
accessible to staff, patients and
the public as they are placed in
each ward/unit or community
team setting throughout the Trust
Demonstrates Compliance as per
national and local policy
Continue to monitor compliance
through the audit process and IP &
C unannounced visits
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Ward Managers
38
Compliance Criterion 8 – Secure adequate access to laboratory support as appropriate
Self assessment Description for compliance Actions responsibility Progress
A provider should ensure that
laboratories used to provide
microbiology services in connection
with arrangements for infection
prevention and control have in place
appropriate protocols and that they
operate according to the standards
required for accreditation by
Clinical Pathology Accreditation
(UK) Ltd.
Protocols should include:
a microbiology laboratory
policy for investigation and
surveillance of HCAI; and
standard operating procedures
for the examination of
specimens.
SLA with Acute Trust’s
Microbiology Services
Demonstrates Compliance as per
national and local policy
Non required Finance department
39
Compliance Criterion 9 – Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.
Self assessment Description for compliance Actions responsibility Progress
9a. Standard (universal) infection
control precautions • The policy
should be
based on
evidence-
based
guidelines,
including
those on
hand
hygiene
and the use
of personal
protective
equipment.
• The policy
should be
easily
accessible
to all
groups of
staff,
patients
and the
public.
• Complianc
e with the
policy
should be
audited.
• Information
on the
policy
should be
included in
induction
programme
s for all
staff groups
Infection Prevention and Control
Policy
Hand Hygiene policy includes 5
moments for hand hygiene at the
point of care
Standard (Universal) Precautions
Policy
Policies are available and
accessible to staff, patients and
the public as they are placed in
each ward/unit or community
team setting throughout the
Trust.
The MRSA Screening policy is
available to the public via the
Infection Control web page on
the Trust website.
Trust wide compliance to IP & C
and Hand Hygiene policy is
audited monthly and a Trust
wide Audit report is produced
annual.
IP & C corporate induction
training includes standard
precautions and covers epic 2
guidelines for all staff groups
Demonstrates Compliance as per
national and local policy
Review of policies to reflect any
changes to guidance relating to
standard (universal) infection
control precautions (should they
occur) is ongoing
Audit to evaluate Trust wide
compliance to policies to continue
For IP & C training programme to
continue
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team,
Service
Managers/Modern
Matrons
40
9b. Aseptic technique
Clinical procedures should be carried out in a manner that maintains and promotes the principles of asepsis.
Education, training and assessment in the aseptic technique should be provided to all persons undertaking such procedures.
The technique should be standardised across the organisation.
Audit should be undertaken to monitor compliance with the technique.
Identified in the Trust Infection
Prevention and Control policy
Staff are trained and evaluated
locally
Aseptic Non Touch Technique
Policy
Demonstrates Compliance as per
national and local policy
Review of policies to reflect any
changes to guidance relating to
aseptic technique (should they
occur) will be ongoing
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
9c. Outbreaks of communicable infection
The degree of detail in the policy should reflect local circumstances to take into account at-risk patients and clinical specialties.
Policies for major outbreaks of communicable infection should include initial assessment, communication, management and organisation, and investigation and control.
The contact details of those likely to be involved in outbreak management should be reviewed at least annually.
Significant outbreaks should be reported as serious untoward incidents.
Formal arrangements should be
in place to fund the cost of
dealing with outbreaks
Identified in the Infection
Prevention and Control policy
Ward Closure (Infection Control)
Policy
Norovirus (Outbreak) policy
Clostridium difficile Policy
Isolation (Nursing) Policy
Pandemic Flu Policy
Policies are available and
accessible to staff, patients and
the public as they are placed in
each ward/unit or community
team setting throughout the Trust
Significant outbreaks of infection
are also reported following the
SUI process and are followed by
root cause analysis (RCA) using
the National Patient Safety
Agency’s RCA tool
Demonstrates Compliance as per
national and local policy
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
9d. Isolation of patients Ward Closure (Infection Control) Demonstrates Compliance as per Continue to monitor compliance Executive Director of
41
The isolation policy should be evidence-based and reflect local risk assessment of in-patients.
Indications for isolation should be included in the policy, as should procedures for the infection control management of patients in isolation.
Information on isolation should
be easily accessible to all
groups of staff, patients and the
public
Policy
Norovirus (Outbreak) policy
Clostridium difficile Policy
Isolation (Nursing) Policy
Policies are available and
accessible to staff, patients and
the public as they are placed in
each ward/unit or community
team setting throughout the Trust
Single Bedrooms available in
most wards/units
national and local policy through the audit process and IP &
C unannounced visits
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
9e. Safe handling and disposal of sharps
Relevant considerations include: risk management and
training in prevention and management of needlestick injuries;
provision of medical devices that incorporate sharps protection mechanisms where there are clear indications that they will provide safe systems of working for healthcare workers;
policy that is easily accessible to all groups of staff;
auditing of policy compliance;
and inclusion of information
on the policy in induction
programmes for all staff
groups.
Waste Management policy
Standard (Universal) Precautions
policy
Taking Specimens for
Microbiological Investigations
policy
Venepuncture Policy
Inocculation (Management of
Sharps injury/splash incidents)
Policy and Procedure
The use of retractable syringes
by clinical staff are being used
Trust wide.
Policies are available and
accessible to staff, patients and
the public as they are placed in
each ward/unit or community
team setting throughout the Trust
All IP & C staff training
programmes, including corporate
induction include the safe
management of sharps and
needlestick injuries
Waste Management training
includes safe disposal of sharps
Demonstrates Compliance as per
national and local policy
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing/ Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
9f. Prevention of occupational
exposure to blood-borne viruses,
Standard (Universal) Precautions
Policy
Occupational Health Policy -
Demonstrates Compliance as per
national and local policy
IP & C Team and Occupational
Health to raise awareness for the
prevention of needle sticks injuries
Occupational Health
Department
42
including prevention of sharps
injuries
Measures to avoid exposure to
blood-borne viruses should include:
immunisation against hepatitis
B;
the wearing of gloves and other
protective clothing;
the safe handling and disposal
of sharps, including the
provision of medical devices
that incorporate sharps
protection where there are clear
indications that they will
provide safe systems of
working for healthcare
workers; and
measures to reduce risks during
surgical procedures.
Management of Sharps
Injury/Splash Incident
The use of retractable syringes
by clinical staff are in use Trust
wide.
PPE’s are available for all
clinical staff
Blood and body fluid spillage
kits on every ward/unit
All IP & C staff training
programmes, including corporate
induction include the safe
management of sharps and BBV
awareness
Surgical procedures are not
performed within a Mental
Health environment
through training programme
Attendance to be monitored by the
Learning and Development
Department
Audit process
IP & C unannounced visits
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Learning &
Development
Department
9g. Management of occupational
exposure to blood-borne viruses
and post-exposure prophylaxis
Management should include:
designation of one or more
doctors to whom healthcare
staff and others may be referred
immediately for advice
following occupational blood
exposure;
provision of clear information
to healthcare staff about
reporting potential occupational
exposure – in particular the
need for prompt action
following a known or potential
exposure to human
immunodeficiency virus (HIV)
or hepatitis B; and
arrangements for post-exposure
prophylaxis for blood-borne
viruses.
Occupational Health Policy -
Management of Sharps
Injury/Splash Incident
identifying actions required post
occupational exposure
All IP & C staff training
programmes, including corporate
induction include the safe
management of sharps, BBV
awareness and safe management
of blood and body fluid spillages
and actions required post
occupational exposure
Demonstrates Compliance as per
national and local policy
IP & C Team and Occupational
Health to raise awareness for the
prevention of needle sticks injuries
through training programme
Attendance to be monitored by the
Learning and Development
Department
Clinical audit process
IP & C unannounced visits
Occupational Health
Department
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Learning and
Development
Department
43
9h. Closure of wards, departments
and premises to new admissions A system should be in place for
the provision of advice by the
DIPC/ICT to the chief
executive and medical director.
There should be clear criteria in
relation to closures.
Management arrangements for
redirecting admissions should
be drawn up with ICT input.
The policy should address the
need for environmental
decontamination prior to
reopening.
Identified in the Trust Infection
Prevention and Control policy
Trust wide IP & C Group
Bi-Monthly Board reports
Environmental
decontamination/deep cleaning is
identified in the Trust Infection
Prevention and Control policy
Ward Closure (outbreak) policy
Norovirus Management Policy
Clostridium difficile Policy
Isolation (Nursing) Policy
Public notice to display on
ward/unit door
Data Surveillance
Demonstrates Compliance as per
national and local policy
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Hotel Services
9i. Environmental disinfection
policy The use of disinfectants is a
local decision, and there should
be local policies on disinfectant
use which focus on specific
infection risks.
If appropriate, the role of high-
level disinfectants to kill
bacteria, viruses and spores
should be considered
Strategic and operation cleaning
policies in place
Demonstrates Compliance as per
national and local policy
To be monitored through the
PLACE process, IP & C Team
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Hotel Services
9j. Decontamination of reusable
medical devices
Effective decontamination of
reusable medical devices is
essential. There should be a
system to protect patients and
staff that minimises the risk of
transmission of infection from
Safe Management of Medical
Devices Policy
Agenda item on the Medical
Devices Management Meeting
IP & C Team promotes the use
Demonstrates Compliance as per
national and local policy
Monitor in Trust wide IP & C
Group and the Medical Devices
Management Meeting
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
44
medical devices and other
equipment that comes into
contact with patients or their
body fluids.
Decontamination is the
combination of processes,
including cleaning, disinfection
and sterilisation, used to render
a reusable item safe for further
use on patients and handling by
staff.
Reusable medical devices and
other devices should be
decontaminated in accordance
with manufacturers’
instructions and current
guidelines.
Systems should ensure
adequate supplies of reusable
medical devices and should
allow reusable medical devices
to be tracked through
decontamination processes in
order to ensure that the
processes have been carried out
effectively.
Systems should also be
implemented to enable the
identification of patients on
whom the medical devices have
been used.
of single patient/single use items.
Medical Devices
Manager
IP & C Team
Service
Managers/Modern
Matrons
9k. Antimicrobial prescribing Local prescribing should,
where appropriate, be
harmonised with that in the
British National Formulary
(BNF).
All local guidelines should
include information on the
regimen and duration of
particular drugs.
Procedures should be in place
to ensure prudent prescribing
and antimicrobial stewardship.
Antimicrobial Prescribing and
Management Policy
MRSA Management and
Screening policy
Surveillance by ICT using
infection reporting structure
includes pharmacy input
Demonstrates Compliance as per
national and local policy
None required Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
Pharmacists
IP & C Team
Service
Managers/Modern
Matrons
45
9L. Reporting HCAI to the HPA
as directed by the Department of
Health
This includes a mandatory
requirement for NHS trust chief
executives to report all cases of
MRSA bacteraemia and all cases of
C. difficile infection in patients aged
two years or older. Reporting should
include procedures for dealing with
serious untoward incidents.
Reporting structure is in place
and is identified in the IP & C
policy.
Reporting procedure flow chart
in nursing offices identifying
contact details of KHPU (looked
for during unannounced visits).
Staff to inform the KHPU of all
suspected/confirmed outbreaks,
which includes MRSA
bacteraemia and C.difficile.
IP & C training programme
identifies reporting
structure/procedure.
Demonstrates Compliance as per
national and local policy
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Ward Managers
Nurse in charge of
shift.
9m. Control of outbreaks and
infections associated with specific
alert organisms This should take account of local
epidemiology and risk assessment.
These infections must include, as a
minimum, MRSA, C. difficile
infection and transmissible
spongiform encephalopathies
MRSA screening policy
Norovirus management
Policy
Clostridium.difficile Policy
Prion disease (transmissible
spongiform
encephalopathies)
Vancomycin Resistant Enterococci (VRE) Policy
Meningococcal Meningitis / Septicaemia Policy
Scabies, Head lice and body lice infestation Policy
Varicella Zoster Virus (VZV) - Chickenpox and Shingles awaiting ratification
Tuberculosis Policy
Demonstrates Compliance as per
national and local policy
To be monitored through the
infection control reporting forms,
Data surveillance
IP&C groups
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing /Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
MRSA The policy should make provision
for:
screening of patients on
admission, which should
include screening of all elective
MRSA screening policy
identifies reasons for screening
mental health service users
(elective and emergency
admissions).
Demonstrates Compliance as per
national and local policy
To be monitored through the
infection control reporting forms,
Data surveillance
IP & C groups
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
46
admissions by March 2009 and
provision for screening of
emergency admissions at
presentation as soon as is
practical;
decontamination procedures for
colonised patients, as
appropriate;
isolation of infected or
colonised patients;
transfer of infected or colonised
patients within NHS bodies or
to other healthcare facilities;
and
antibiotic prophylaxis for
surgery.
They may have other clinical
conditions that may put them at
risk of
MRSA infection and should be
screened for that reason.
Isolation (Nursing) Policy
Ward Closure policy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
C. diffi cile
The policy should make provision
for:
surveillance of C. diffi cile
infection; diagnostic criteria;
isolation of infected patients
and cohort nursing;
environmental
decontamination;
antibiotic prescribing policies;
and a statement concerning
contraindication of antimotility
agents in symptomatic
antimicrobial-associated
diarrhoea
Clostridium difficile` Policy
Isolation (Nursing) Policy
Ward Closure policy
Demonstrates Compliance as per
national and local policy
To be monitored through infection
control reporting forms,
Data surveillance
IP & C groups
Drug & Therapeutic
Committee
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Transmissible spongiform
encephalopathies
The policy should make provision
for the management of known or
high-risk patients.
Prion disease (transmissible
spongiform encephalopathies)
Demonstrates Compliance as per
national and local policy
To be monitored through infection
control reporting forms,
Data surveillance
IP & C Team
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing /Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
47
Relevant policies for other specific
alert organisms
The specific alert organisms and
matters that follow are relevant to
any acute trust. They may also be
relevant to certain other NHS bodies
to which criterion 8 applies,
depending on their spectrum of
activity.
Glycopeptide-resistant enterococci:
screening of high-risk groups;
isolation and prevention of
cross-infection; and
prophylaxis for surgical
procedures.
Acinetobacter and other antibiotic-
resistant bacteria:
surveillance of identified
patients at risk and of high-risk
environments; and
procedures for managing
infected patients to prevent
spread of infection.
Control of tuberculosis, including
multi-drug-resistant tuberculosis:
isolation of infectious patients;
transfer of infectious patients
within NHS bodies or to other
healthcare facilities; and
treatment compliance.
Respiratory viruses:
alert system for suspect cases;
isolation criteria;
infection control measures; and
terminal disinfection and
discharge.
Diarrhoeal infections:
isolation criteria;
infection control measures; and
cleaning and disinfection policy.
Vancomycin Resistant Enterococci (VRE) Policy
Tuberculosis Policy
dentifies the care of Patients with confirmed or suspected tuberculosis and Directly Observed Therapy (DOT)
Norovirus Management
Policy
Clostridium.difficile Policy
Meningitis / septicaemia
Policy
The Infection Prevention
and Control policy
identifies
cleaning/disinfection
following outbreaks
Acinetobacter Policy
VHF policy
Demonstrates Compliance as per
national and local policy
To be monitored through infection
control reporting forms,
Data surveillance
IP & C Team
Executive Director of
Nursing and
Governance/DIPC,
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
48
Viral haemorrhagic fevers (VHF):
patient risk assessment and
categorisation;
appropriate staff to be aware of
the special measures to be
taken for nursing VHF patients,
and to be properly trained in
the application of full isolation
procedures;
confirmed cases to be handled
under full isolation measures in
a high-security infectious
diseases unit or equivalent;
handling of patient specimens
at the appropriate containment
level;
follow-up of all staff in contact
with the patient at every stage
of care; and
special measures for the
handling of all healthcare
waste.
Legionella:
premises should be
regularly reviewed for
potential sources of
infection, and a
programme should be
prepared to minimise any
risks. Priority should be
given to patient areas,
although the exact priority
will depend on local
circumstances.
Any provider that should have in
place any of the core policies
mentioned above should, having
The Control of Legionellae
Bacteria in Trust Premises
policy
49
regard in particular to the healthcare
it provides, also consider whether it
would be appropriate for it to have
in place any of the additional
policies or to take any of the
measures mentioned in Part 5 of this
Code with a view to minimising the
risk of HCAI.
If such a provider considers that it is
appropriate for it to have in place
any of those policies or take any of
those measures, it should take into
account the content of Part 5 insofar
as it is relevant to making those
arrangements, including the content
of guidance and other publications
referred to in any relevant citation.
The sufficiency and suitability of
any policy implemented in
accordance with this provision of
the Code should be monitored via
the clinical governance system, and
there should be evidence of a rolling
programme of audit, revision and
update.
All policies should be clearly
marked with a review date.
50
Compliance Criterion 10 – Ensures, so far as is reasonably practicable, that care workers are free of and are protected from exposure to
infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the
provision of health and social care.
Self assessment Description for compliance Actions responsibility Progress
All staff can access relevant occupational health services
In Place Demonstrates Compliance as per
national and local policy
Up date as new guidance is issued
Review and develop training
sessions across all services as
required.
Learning and Development
Department to monitor attendance
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing / Deputy
DIPC
IP & C Team
Service
Managers/Modern
Matrons
Learning &
Development
Department
Occupational Health
Dept
Occupational health policies on the
prevention and management of
communicable diseases in healthcare
workers, including immunisation,
are in place
In Place
Prevention and control of infection is included in induction programmes for new staff, and in training programmes for all staff
In Place
Training and development
department records
There is a programme of ongoing
education for existing staff
(including support staff,
agency/locum staff and staff
employed by contractors);
In Place
Training and development
department records
There is a record of relevant
immunisations;
In Place
There is a record of training and
updates for all staff
In Place
51
Training and development
department records
The responsibilities of each member
of staff for the prevention and
control of infection is reflected in
their job description and in any
personal development plan or
appraisal.
In place - Job descriptions Completed by IP & C team, HR
and AD’s working together.
Executive Director of
Nursing and
Governance/DIPC
Deputy Director of
Nursing/ Deputy
DIPC
Service
Managers/Modern
Matrons
Trust-wide Board Report May 2015
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