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Trust Board

    INFECTION PREVENTION ANDCONTROL POLICY

    1 of 11 Page

    INFECTION PREVENTION Date of issue: 03/07/07 Document Control Sheet

    TITLE: Infection Prevention and Control Policy

    UNIQUE IDENTIFIER Assigned by SharePoint

    1.2 VERSION No

    Paul Godwin LEAD AUTHOR’S NAME

    Director of Infection prevention and LEAD AUTHOR JOB TITLE Control

    Director of Nursing ACCOUNTABLE DIRECTOR

    Board Committee Group APPROVED BY (1) Infection Control Committee th 25 April 2007

    Quality Assurance Committee nd2 July 2007 thAmendment 14 November 2007

    Clinical Governance and Risk

    Management Operational Committee nd2 July 2007 DATE APPROVED

    Board Committee Group APPROVED BY (2) Trust Board th 24 July 2007

    Quality Assurance Committee thAmendment 7 November 2007

    Quality Safety and Assurance

    Committee thAmendment 6 June 2008 thAmendment 14 January 2009 nd2 July 2007 DATE APPROVED rd3 July 2007 EFFECTIVE FROM

    June 2009 REVIEW DATE

    SharePoint LOCATION OF COPIES

    COSSH ASSOCIATED

    POLICIES & PROCEDURES

    DOCUMENT REVIEW HISTORY

    REVIEW DATE REVIEWED BY

DOCUMENT CHECKED FOR

    Name: Allison Charlesworth

    COMPATIBILITY WITH OTHER TRUST DOCUMENTS Yes EQUALITY, DIVERSITY & RACE RELATIONS IMPACT Yes Kuldip

    Sohanpal RISK ASSESSMENT Yes Airedale NHS Trust Infection Prevention and Control Policy 1

    COST IMPACT Yes LEGAL ISSUES Yes TRAINING & EDUCATION NEEDS Yes DISTRIBUTION LISTS Yes

     Page No

    3 Trust Statement of Intent

    3 1. Introduction

    3 2. Scope

    3 3. Policy Statement

    4 4. Implementation

    7 5. Equality & Diversity

    7 6. Consultation

    7 7. Monitoring and Evaluation

    8 8. References

    9 9. Appendix

    Airedale NHS Trust Infection Prevention and Control Policy 2

Trust statement of intent

     “Airedale NHS Trust is committed preventing and reducing healthcare

    associated infections. This is achieved through the Infection Prevention and Control Policy, which provides the framework to support effective management of infection control across the Trust.

1. Introduction

    High standards of infection prevention and control, hygiene and the provision of a clean and well-maintained environment are at the heart of the successful delivery of healthcare services. This policy will set out the mechanism for effective management of infection control across the Trust.

2. Scope

    This policy is mandatory and applies to all Airedale NHS Trust staff, both clinical and non-clinical in all clinical areas of the Trust.

3. Policy Statement

    There are a number of statutory requirements that Airedale NHS Trust must adhere to in the prevention and control of infection within healthcare. These include:

    The Health Act 2006, Code of Practice for the Prevention and Control of Health Care Associated Infections. Department of Health (2006)

    Saving Lives: a delivery programme to reduce Health care Associated Infection (HCAI) including MRSA. Department of Health (2006)

Standards for Better Health, Department of Health (2004)

    Winning Ways Working Together to Reduce Healthcare Associated Infection. Department of Health (2003)

    Getting Ahead of the Curve. A strategy for combating infectious diseases (including other aspects of health promotion). Department of Health (2002)

    The Management and Control of Hospital Infection. Health Service Circular (2000) HSC 2000/002

    The Management and Control of Hospital Acquired Infection in Acute Trust in England in 2000. National Audit Office (2000)

    Hospital Infection Control. Health Service Guidance HSG (95) 10. Department of Health (1995)

Airedale NHS Trust Infection Prevention and Control Policy 3

4. Implementation

Trust Board

    The Trust Board has overall responsibility for ensuring that adequate resources are provided for infection prevention and control and for monitoring the impact of the policies of the Trust and its management. This is achieved by considering the Annual Report from the Director of Infection Prevention and Control, the regular clinical governance monitoring reports and the reports of the Executive Officers.

Chief Executive

    The Chief Executive is responsible for ensuring that there are robust and effective arrangements for infection prevention and control within Airedale NHS Trust. Clear lines of accountability should be established between the Infection Prevention Team (IPT), the Infection Control Committee, The Clinical Governance and Risk Operation Committee, the Quality and Assurance Committee and the Trust Board.

Director of Nursing

    The Director of Nursing takes lead Board responsibility for infection prevention and control.

Director of Infection Prevention and Control (DIPC)

    The DIPC will have overall responsibility for creating a culture of effective hygiene practice and will ensure the effective day-to-day organisation of infection prevention and control within Airedale NHS Trust. The DIPC will report directly to the Chief Executive concerning infection prevention and control matters and will produce an annual report of the state of infection prevention and control within the organisation and the resources required to aid decision making by the Trust Board.

Infection Control Committee

    The Infection Control Committee is a mandatory requirement, which meets four times a year. It is the key forum in providing assurance that the Trust has in place appropriate structures and arrangements to discharge its responsibilities for Clinical Governance and Risk Management. The Committee reports to the Clinical Governance and Risk Operational Committee (CGROC) and the Quality Safety and Assurance Committee (QSAC)

    It is responsible for:

    ; Producing Policies concerning infection prevention and control

    ; Ensuring the implementation of National and Local Policies and guidance

    ; Monitoring the implementation of the policies

    ; Auditing practices of staff relevant to controlling the spread of healthcare

    associated infection

    ; Overseeing training in infection prevention and control

    ; Providing advice to the DIPC, Chief Executive and Trust Board

Airedale NHS Trust Infection Prevention and Control Policy 4

Infection Prevention Implementation Group

    The Infection Prevention and Implementation Group is the working group of the Infection Control Committee. The group meets on a monthly/bi-monthly basis. The group reports to CGROC. The membership of the group is Modern Matrons, Hotel Services, the antibiotic pharmacist and the Infection Prevention Team. The group is responsible for:

    ; Ensuring the ongoing coordination of advice to the nursing staff

    concerning infection prevention and control

    ; Ensuring the regular discussion of cleaning and hygiene standards

    ; Monitoring progress in relation to the infection prevention and control

    targets.

    For membership and terms of reference please see appendix 1.

Specialist Infection Prevention and Control Advice

    Airedale NHS Trust has an Infection Prevention Team led by the DIPC/Consultant Microbiologist along with the Matron for Infection Prevention and Infection Prevention Nurse Specialists.

    The responsibilities of the team are:

    ; To give advice on all aspects of infection prevention and control

    ; To ensure that relevant policies and guidelines are in place and

    implemented appropriately

    ; To review arrangements for infection prevention and control as necessary

    ; To give advice concerning the design and of new facilities and the

    refurbishment of existing ones

    ; To provide infection prevention and control advice concerning the

    provision of new clinical and other services including catering cleaning and

    laundry

    ; To provide advice concerning the management of individual patients

    ; Outbreak management, including liaison with the Health Protection

    Agency, Local Authority and Primary Care Trust

    ; To undertake audit of the implementation of policy

    ; To provide educational programmes in infection prevention and control

    ; The Trust has the following information leaflets available for both patients

    and staff:

    Clostridium difficile

    MRSA

    MRSA screening

    Hand Hygiene

    Norovirus

Modern Matrons and Specialist Nurses

    Modern Matrons and Specialist Nurses will work with the Infection Prevention Team create a culture of effective hygiene practice by:

    ; Ensuring that infection prevention and control Policies and guidance are

    distributed and communicated to the staff in their areas

    Airedale NHS Trust Infection Prevention and Control Policy 5

    ; Ensuring procedures pertinent to the specialty are in place, in liaison with

    the Infection Prevention Team

    ; Ensuring staff co-operate with regular audits of compliance to the policy,

    procedures and guidance

    ; Reporting occupational diseases to comply with RIDDOR regulations, in

    co-operation with the Department of Occupational Health

    ; Ensuring that advice is sought from the Infection Prevention Team prior to

    the purchase of equipment regarding the risk presented to patients

    ; Ensuring that staff are aware of COSHH assessments and that defined

    operational procedures are followed

Responsibilities of Medical Staff

    Medical staff are expected to implement the Infection Control Policies and guidelines of the Trust and in the case of Consultants, ensure that these are followed in relation to their patients. Consultant staff have an additional responsibility in ensuring that their junior staff have received adequate training and support the other Trust staff in carrying out practices, in relation to infection prevention and control. Infection prevention and control issues must be discussed as part of appraisal by all staff with clinical responsibilities.

Responsibilities of individual members of staff

    All members of staff are required to follow the infection prevention and control policies of the Airedale NHS Trust. All members of staff must ensure that they report incidents of infection that may result in spread between patients. All staff must ensure that they attend mandatory training in infection prevention and control practices as required by the Trust.

Infection Prevention and Control Training

    It is a mandatory requirement that all new Trust employees must attend a Trust corporate induction programme, which includes infection prevention and control training. It is the responsibility of the line manager to ensure that infection prevention and control issues are covered in all local inductions and documented.

    It is a mandatory requirement that all clinical staff attend an infection prevention and control update session annually. It is the line manager‟s responsibility to

    ensure that staff attend training.

    For staff / individual training requirements and methods of delivery please refer to: The Trust Training Matrix, Training Strategy for Infection Prevention and Control, Hand Hygiene and Infection Prevention and Control Quiz Road Show Timetable, Ultraviolet Light Box Rotation Schedule.

    Line managers should consider infection control as part of the KSF personal development plans, appraisals and reviews for all staff.

Infection Prevention and Control Assurance Framework

Refer to „Saving Lives‟ self assessment document.

    The core clinical protocols as dictated by the Health Act (2006) which support the process for managing the risks associated with infection prevention and control are contained in the following Trust Guidelines.

    Airedale NHS Trust Infection Prevention and Control Policy 6

    ; Aseptic Technique (refer to Marsden Manual)

    ; Hand Hygiene

    ; Universal Precautions

    ; Prevention and Management of Inoculation and Blood Contamination

    Injuries

    ; Management of Transmissable Spongiform Encephalopathy

    ; Management of Clostridium difficile

    ; Management of MRSA

    ; Antibiotic Policy

    ; Outbreak Control / Closure of Wards

    ; Major Outbreak

    ; Isolation of Patients

    ; Decontamination, Cleaning and Disinfection

5. Equality & Diversity

    Airedale NHS Trust is committed to creating and promoting equal rights and diversity and to working towards eliminating all forms of discrimination, inequality, exclusion, victimisation, harassment and bullying.

6. Consultation

    This policy has to meet statutory requirements and has been developed by the Director of Infection Prevention and Control. It will be consulted upon through the Clinical Governance and Risk Management Operational Committee (CGROC).

7. Monitoring and Evaluation

    Surveillance

    Surveillance is the key component of an infection prevention and control programme. It consists of the routine collection of data on infections among patients and staff, its analysis and dissemination of results to those who need to know in order that appropriate action can be taken.

    Surveillance aims to produce timely information on infection rates and trends, detect outbreaks, inform evaluations of and changes in clinical practice, and assist the targeting of preventative efforts.

    Airedale NHS Trust will undertake the following surveillance as part of its infection prevention and control programme:

MRSA septicaemia cases

    C. difficile cases

    Adherence to Trust infection prevention and control guidance

    High Impact Intervention observational audits

The full plan for the year is stated in the Annual Infection Control Report.

Monitoring/Audit arrangements

    The Infection Control Committee will review the effectiveness of the policy annually.

    Airedale NHS Trust Infection Prevention and Control Policy 7

    The Trust Board will monitor infection prevention and control through the committee structure and the submission of quarterly reports and the Infection Control Annual Report.

    Infection prevention and control practice will be audited through the infection prevention and control audit programme as agreed by the Infection Control Committee on a yearly basis. Results of the audits will be discussed at the Infection Control Committee, Infection Prevention Implementation Group and CGROC and changes in practice implemented as required. Where relevant action plans will be issued with audit reports and ongoing follow up monitored monthly by the Infection Prevention Team at their team meeting.

8. References

    The Health Act 2006, Code of Practice for the Prevention and Control of Health Care Associated Infections. Department of Health (2006)

    Saving Lives: a delivery programme to reduce Health care Associated Infection (HCAI) including MRSA. Department of Health (2006)

Standards for Better Health, Department of Health (2004)

    Winning Ways Working Together to Reduce Healthcare Associated Infection. Department of Health (2003)

    Getting Ahead of the Curve. A strategy for combating infectious diseases (including other aspects of health promotion). Department of Health (2002)

    The Management and Control of Hospital Infection. Health Service Circular (2000) HSC 2000/002

    The Management and Control of Hospital Acquired Infection in Acute Trust in England in 2000. National Audit Office (2000)

    Hospital Infection Control. Health Service Guidance HSG (95) 10. Department of Health (1995)

Appendix 1

    AIREDALE GENERAL HOSPITAL

    HOSPITAL INFECTION CONTROL COMMITTEE

Airedale NHS Trust Infection Prevention and Control Policy 8

Hospital Infection Control Committee (ICC) meets quarterly.

Current Membership

Director Infection Prevention and Control (Chair) Dr Paul Godwin

Matron Infection Prevention Miss A Charlesworth

    Infection Prevention Nurse Specialist Miss Samantha Moorehouse

    Infection Prevention Nurse Specialist Mr Gary Thirkell Infection Prevention Nurse Specialist Mrs Anne Choyce Infection Prevention and Control Manager (community) Miss Susan Campbell TB Liaison Nurse Mrs Janet Anderson

    Microbiology Manager Mrs Anne Crabtree

    Service Manager Pathology Mr Shaun Milburn

Head of Planning and Performance Mr Stuart Shaw

    Director of Nursing Mrs Bridget Fletcher

    Assistant Director of Nursing Mrs Debra Fairley

    Non Executive Director Yet to be filled

Consultant Physician Medicine for the Elderly Dr Daphne Allen

    Consultant Surgeon Mr Ali Nejim

    Senior Matron Medicine Mrs Karen Walker Senior Matron Surgery Mrs Linda Beckett

    Practice Development Manager Airedale Primary Care Trust Ms Helen Torevell

Hotel Services Manager Mrs Wendy Firth

Manager SSD Mrs Ann Rodgers

    Director Pharmacy & Clinical Professions Professor Peter Taylor

Occupational Health Services Manager Mrs Karen Swann

CCDC North Yorkshire Health Protection Unit Dr Louise Coole

    Public Health Nurse North Yorkshire HPU Ms Wendy Bradley

    CCDC Bradford Health Protection Unit Dr Martin Schweiger

    Public Health Nurse Bradford Health Protection Unit Mrs Jane Reid

Service Manager Women‟s and Children‟s Health Mrs Kath Walsh

Risk Manager Mrs Eve Scott

Frequency of attendance:

    It is expected that each member, or their nominated and appropriate representative will attend all meetings

    Airedale NHS Trust Infection Prevention and Control Policy 9

Purpose:

    The aim of the Trust‟s Infection Control Committee is to govern practice in all matters relating to infection prevention and control in order to ensure safe, effective and evidence based practice in accordance with national and local guidance and contribute to the delivery of key national targets in accordance with the Trust‟s performance management framework

Terms of Reference:

    In order to promote safe, effective evidence based care the ICC will:

1. Advise and support the Infection Prevention Team (IPT)

    2. Draw the attention of the Chief Executive to any major issues relating to the

    prevention and control of infection.

    3. Consider reports on infections and infection prevention and control problems.

    4. Discuss and endorse a plan for the management of outbreaks in the hospital,

     and monitor its implementation.

    5. Discuss and endorse a plan for the hospital response to major outbreaks in the

    community the Major Incident (Outbreaks) Plan and monitor its implementation.

    6. Discuss and endorse the annual infection prevention and control programme

     which will be submitted to the Trust Board, review the progress of the

     programme, assist in its effective implementation and review the final results.

    7. Advise on the most effective use of resources available for implementation

     of the programme and for contingency requirements.

    8. Advise on and approve infection prevention policies, guidelines and standard

     operating procedures before their submission for the Management Board‟s

     approval and review their implementation.

    9. Promote and facilitate the education of all grades of hospital staff in infection

     Prevention and control procedures.

    10. Encourage communication among the different disciplines involved.

     The minutes of the Hospital Infection Control Committee meetings should be

     widely circulated and made accessible to senior medical and nursing staff and

     appropriate committees.

AC/JMR/InfectPrev/ICCMembership+Terms of reference

    Updated November 2008/Review 2010

    AIREDALE GENERAL HOSPITAL

    INFECTION PREVENTION IMPLEMENTATION GROUP

    The Infection Prevention Implementation Group (IPIG) meets monthly/bimonthly.

Airedale NHS Trust Infection Prevention and Control Policy 10

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