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INFECTION PREVENTION &CONTROL ASSURANCE FRAMEWORK & ROLES AND RESPONSIBILITIES

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Document Control Information

Author: Sue Dailly Lead Infection Prevention & Control Nurse

Type: Policy

Sponsor: Paula Shobbrook Chief Nurse & Director of Infection Prevention & Control

Scope: Major

Trust Reference Number:

CP074

Reviewer(s): Infection Prevention & Control Committee Risk Management & Governance Committee

Issue Number: 2

Approval body:

Policy Approval Group Status: Published

Effective Date: January 2011

Review Date: January 2014

Disposal Date: 2036

Document Authorisation Control Prepared By: Sue Dailly Lead Infection Prevention & Control Nurse

Authorised Officer Chris Gordon Chief Executive

Signature:

Signature:

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Author: Sue Dailly, Lead Infection Prevention & Control Nurse

Type: Policy

Sponsor: Paula Shobbrook, Director of Infection Prevention & Control

Scope: Major

Reference: CP074 Issue Number: 2 Date January 2011 Status: Published

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Winchester & Eastleigh Healthcare NHS Trust Infection Control Assurance Framework & Roles and Responsibilities

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DOCUMENT CONTROL

Document Amendments Number Details By Whom Date 1.0 Amended to match Trust Policy for the

Management of Controlled Documents and NHSLA Standard 1.4.9

NHSLA Project Lead

23/01/08

2.0 3 yearly review changes to names K. Davis-Blues IPCN

Oct’10

Review Timetable Date Reason By

Whom Date Completed

October 2013 Three yearly review cycle for policy document. If national guidance changes the policy will be reviewed sooner

Infection Prevention and Control Team

Distribution List No Title 1 All Winchester and Eastleigh Health Care NHS Trust employees

via intranet 2 The Public via the Winchester and Eastleigh Health Care Website


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RELATED TRUST POLICIES The Policies listed below include the 12 core clinical care protocols as stated in the NHSLA guidance: OP001 Policy for the management of controlled documents CP021 Surveillance Policy ( includes reporting of healthcare associated infections to the Health Protection Unit) CP022 Isolation and infectious disease policy CP030 Overarching Decontamination policy CP060 Aseptic technique policy CP071 Major outbreak plan CP077 Policy for ward closure due to an infection control issue CP076 Standard precautions and Personal Protective Equipment Policy (incorporating safe handling of sharps and prevention of exposure to blood borne viruses.) CP073 Hand hygiene Policy OP006 Risk management and patient safety policy CP072 Training policy for employees of WEHCT in infection control Trust Training Policy CP028 Management of suspected cases of viral haemorrhagic fever CP029 New strain influenza CP047 Tuberculosis and multiple drug resistant tuberculosis CP055 MRSA policy CP064 Clostridium difficile policy CP070 Deceased infected patient policy CP075 Protective isolation policy CPr031 CJD and other transmissible spongiform encephalopathy guidelines


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Contents Section Title Page 1.0 INTRODUCTION 5 2.0 PURPOSE 5 3.0 SCOPE 5 4.0 IPCT INFRASTRUCTURE 6 5.0 DUTIES, ROLES AND RESPONSIBILITIES OF THE

IPC TEAM 6

6.0 TRUST ASSURANCE 10 7.0 IPCC ASSURANCE 11 8.0 TRUST BOARD ASSURANCE 12 9.0 REPORTING TO STAFF AND PUBLIC 12 10.0 NATIONAL REPORTING 13 11.0 MONITORING OF COMPLIANCE, PERFORMANCE

AND EFFECTIVENESS OF INFECTION CONTROL 13

12.0 STAFF TRAINING 14 13.0 RESPONSIBILITIES OF PERSONNEL 14 14.0 WHEN SHOULD HEALTCARE STAFF CONTACT

INFECTION PREVENTION &CONTROL 15

15.0 DEFINITIONS AND ABBREVIATIONS 16 16.0 REFERENCES 17 Appendix 1 Contact & Telephone Numbers 19 Appendix 2 Responsibilities of the IPCC 20 Appendix 3 Guidance regarding Infection Prevention &

Control Policies 21

Appendix 4 Equality Impact Assessment Tool 22


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1 INTRODUCTION 1.1 Healthcare associated infections (HCAIs) are any infections that develop

as a result of healthcare treatment from which the patient was not suffering or incubating at the time of admission to hospital or visit to the general practioner (GP). A national prevalence study in 2006 found 8.2% of patients in England had a hospital acquired infection. In 1993 the rate was 9%. Age was identified as a major risk factor. The rate was 8.7% for those aged over 65 and 5.6% for those aged under 65. (3rd National Prevalence Study 2006)

In 1993 the Prevalence study found 50% of the patients in hospital were aged over 65. By 2006 the rate had increased to 64%

1.2 The type of patient being cared for and the interventions taking place mean

that some HCAI is inevitable but it is estimated that approximately one third is preventable. The prevention of HCAI depends on the application of science and logic. Unfortunately this is often forgotten and ritualistic practices continue.

2 PURPOSE 2.1 The aim of this document is to clarify and explain accountabilities, including

role, membership and responsibilities of the Infection Prevention and Control Service at the Winchester and Eastleigh Healthcare NHS Trust (WEHCT).

2.2 The purpose of Infection Prevention and Control (IPC) is to minimise the risk

of acquisition and spread of infection. It is intended in this policy to put forward a simple and logical approach to IPC which is both up to date and evidence based.

2.3 This policy is ratified in accordance with OP001 the Trust’s Policy for the

Management of Controlled Documents. 3 SCOPE 3.1 This policy is for the use of all staff of the Winchester and Eastleigh

Healthcare NHS Trust. All staff involved directly and indirectly in care have a responsibility to reduce the risk of infection to patients and also to work in a way that affords themselves protection against occupationally acquired


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infection. By implementing the 12 core IPC policies the risk of acquiring an infection for staff and patients will be reduced.

3.2 The Infection Prevention and Control Team (IPCT) has no service level

agreement to provide community infection control services for the local Primary Care Trust (PCT) but has working relationships with local PCTs e.g. investigation of MRSA bacteraemia via root cause analysis.

3.3 The IPCT does have a service level agreement with Hampshire Partnership

Trust to provide advice about alert organisms and conditions and provide an initial response to outbreaks.

3.4 The Health Protection Unit (HPU) has a representative who sits on the

Infection Prevention & Control Committee (IPCC) and is also contacted directly if required.

4 IPCT INFRASTRUCTURE

The Infection Prevention and Control Team Infrastructure encompass the following elements:

4.1 An IPCT 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.

4.2 There should be 24 hour access to a nominated qualified Infection

Prevention and Control Doctor. 4.3 There should be a designated Director of Infection Prevention and Control

within the Trust. 5 DUTIES, ROLES AND RESPONSIBILITIES OF THE INFECTION

PREVENTION & CONTROL TEAM 5.1 The main role of the IPCT is to ensure that there is a system in place to

reduce the risk of hospital acquired infections (HAI) as well as adequately manage the unavoidable ones.

5.2 The IPCT is primarily involved in infection prevention and control policy

development, surveillance, audit and education and training of all staff in infection prevention and control.


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5.3 The IPCT provides a ward based pro-active service and is linked to bed management teams.

5.4 The team assess and takes steps to reduce or control infection risk within

the Trust. 5.5 The team is available to provide infection prevention and control input to

policy development, service development and premises development activity within the Trust. This includes working with Estates and Facilities to ensure the provision and maintenance of a clean and appropriate environment for healthcare. It depends on the infection prevention and control team being consulted adequately and in a timely way.

5.6 The IPCT works closely with the Occupational Health and Safety

Department to develop policies for the protection of healthcare workers from exposure to communicable infections during their work.

5.7 The IPCT produces as annual infection prevention and control programme

with clearly defined objectives and the Director of Infection Prevention and Control’s annual infection control report, which outlines the progress of the programme.

5.8 The current infection prevention and control committee (IPCC) structure is

based on the recommendations in Winning ways, Matrons Charter and the National Audit Office.

5.9 The IPCT meets weekly. The IPCT consists of

• Director of Infection Prevention and Control (DIPC) – not an IPCT

member but should liaise regularly with team members as necessary • Infection Prevention &Control Doctor/Consultant Microbiologist • Infection Prevention &Control Nurses (IPCN) • Antibiotic Pharmacist • Administration support.

5.10 The Health Act 2008 requires the designation of a DIPC within the Trust. The Role of the DIPC is:

• Be responsible for the IPCT within the Trust • Oversee local control of infection policies and their implementation • Report directly to the Chief Executive and the Board • Have the authority to challenge inappropriate clinical hygiene practices

as well as inappropriate antibiotic prescribing decisions


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• Assess the impact of all existing and new policies and plans on HCAIs and make recommendations for change

• Be an integral member of the Trust’s Clinical Governance and Patient Safety Team

• Produce an annual report on HCAIs in the Trust and release it publicly 5.11 The role of the Infection Prevention and Control Doctor (IPCD)

• IPCDs have experience in the microbiology and epidemiology of hospital

infection and in the methods for its prevention and control. • IPCDs take a lead role in the effective functioning of the Infection

Prevention & Control Team (IPCT). • The IPCD chairs the IPCT meetings on a weekly basis and is an active

member of the Trust’s Infection Prevention &Control Committee (IPCC). • The IPCD writes the annual plans, policies and long term programmes

for the prevention of HCAI. • The IPCD should manage the Infection Prevention & Control budget and

the Trust deals with contingency funding for outbreaks of infection.

5.12 Duties of the IPCT under the leadership of the IPCD, include:- • specialist advice • surveillance, including MRSA and Clostridium difficile national data

collection, but not confined to these • investigation and control of outbreaks of hospital infection • preparation and revision of policies including the 12 core clinical care

protocols as required by the National Health Service Litigation Authority (NHSLA) (see Related Trust Policies section in this policy for details)

• direct advice to the Chief Executive, as appropriate • advice in preparation of tender documents and on infection aspects of

these services • setting of quality standards and audit of infection • involvement in planning and upgrading of hospital facilities • liaison with other IPCTs and Consultants in Communicable Disease

Control • involvement in training • provision of out of hours advice.

5.13 The IPCDs support and advise the IPCN(s) in their day to day activities and

may delegate duties to them, as appropriate.

5.14 The role of the Infection Prevention & Control Nurses (IPCN)


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• The main aim of the IPCN is to help prevent patients and staff from sustaining a HCAI. This is achieved through the education of staff both directly and via the Infection Prevention & Control Link Practitioners (IPCLPs).

• Advice is given to all staff about the care of patients with communicable diseases, and those colonized or infected with resistant bacteria. The IPCNs often acts as a communication link between different departments such as the wards, physiotherapy department and theatres.

• The IPCNs will be involved in investigating outbreaks of infection and advising the ward staff and managers how to deal with the outbreak.

• Infection Prevention & Control policies, protocols and procedures have to be written and kept up to date to assist staff in carrying out good quality patient care. Audits of infection prevention & control practices using the Saving Lives care bundle (Department of Health) approach and the inspecting the hospital environment assist in ensuring that policies are being put into practice.

• The IPCNs assist in the introduction of new products into the Trust which will assist in reducing the HCAIs e.g. patient wet wipes and needle protection devices. Assisting with research and trials like drug trials also help to improve the quality of the care we give our patients.

• Serving on committees like Health and Safety, Nursing Policy and Housekeeping, helps to ensure infection preventon and control issues get a wide audience and are taken into consideration when new developments are planned.

• The IPCNs are organisationally managed by the Nursing Directorate and are responsible to the Consultant Microbiologists/Infection Prevention & Control Doctors and the Chief Nurse and DIPC.

• Assist in the root cause analysis carried out for MRSA bacteraemia, Clostridium difficile deaths and other serious events associated with infection control. Information will be shared at Divisional Management meetings and at IPCC meetings. The Infection Prevention and Control Annual report will contain a summary of the incidents, their causes and actions carried out. This will go via Risk Management & Governance Committee to the Trust Board.

• Entering Clostridium difficile and other surveillance data on the web site for the Health Protection Unit.

5.15 The role of the Antimicrobial pharmacist

• promote the safe, prudent and effective use of antimicrobial agents • actively manage policies and guidance related to antimicrobial use • monitor usage and expenditure of antimicrobials in the Trust • report on behalf of the Antibiotic Management Team • provide training to pharmacy staff related to infection management.


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5.16 The role of the Infection Prevention & Control Administration Assistant • Keep the MRSA, ESBL and Clostridium difficile data bases up to date • Assist in the design of audit tools and leaflets • Produce statistics, tables and graphs • Assist in the dissemination of reports • Provide administrative and secretarial support to the IPCT.

6.0 TRUST ASSURANCE The assurance framework is the means by which the Trust assures the Board that it is meeting its strategic objectives. Principle risks to the achievement of the those strategic objectives are defined and monitored through the assurance framework and thus brought to the attention of the Trust Board

6.1 Activities to demonstrate that infection prevention & control is an integral

part of Clinical and Corporate Governance will include: • Regular presentations from the DIPC and/or the IPCT to the Board and

Risk Management and Governance Committee • The review of statistics on incidence of alert organisms (e.g. MRSA,

Clostridium difficile) and conditions, outbreaks and Serious Incidents Requiring Investigation (SIRI) monthly by the Board.

• Feedback to Risk Management and Governance Committee • Review will also be through the IPCC and the DIPC’s annual report. • An audit programme to ensure that policies have been implemented and

are complied with is included in the Infection Prevention & Control programme.

• Adequate arrangements are in place for infection prevention and control to include policies, surveillance, training and audit programmes led by an Infection Prevention and Control Team (IPCT).

• Infection prevention and control advice is provided by a suitably qualified team to include a DIPC, and IPC doctor and IPCNs.

• The IPCT is supported by an adequately resourced and staffed microbiology laboratory capable of promptly processing and reporting results on specimens sent for investigation.

• Multi-professional Infection Prevention & Control and Decontamination Committees are in place to advise and support the IPCT.

• All management/executive and Trust staff are aware of the rationale for maintaining high standards of infection control at all times and their associated responsibilities.

7 INFECTION PREVENTION & CONTROL COMMITTEE ASSURANCE


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The main responsibilities of the IPCC will be: • To collaborate with the IPCT to develop the annual programme and monitor

progress • To ensure incorporation of infection prevention and control into all clinical

and non-clinical activities of the trust e.g. bed allocations, new purchases and building work.

• To endorse all infection prevention & control policies, including the 12 core policies, procedures and guidelines.

• To provide advice and support on implementation of policies. • To monitor Trust performance in nationally reportable infection rates. • To monitor compliance with the Health Act 2006. • To agree the IPC annual report.

7.1 Membership

• Chair • Director of Infection Prevention and Control • Infection Prevention and Control team • Divisional Infection Prevention and Control Leads: medicine, surgery,

orthopaedics, maternity and family services, CADS • Chief Nurse or Deputy/Medical Director (whichever is not the DIPC) • Lead nurses from each division • Representatives from Risk & Clinical Governance as required • Senior clinical risk managers • Deputy Director of Quality and Patient Safety (Deputy DIPC) • Housekeeping representative • Hotel services Manager • Estates Manager • Clinical Sterile Services Department Manager • Chief pharmacist or representative • Occupational Health advisor/doctor • Representative from the PCT • Representative from Hampshire Partnership Trust • Representative from the HPU

Other members may be co-opted as necessary e.g. Health and Safety Advisor, Endoscopy Manager. The IPCC will meet at least quarterly. The roles and responsibilities of the IPCC are in Appendix 2

7.2 The following is monitored by the IPCT and discussed with the IPCC:


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• Alert organism infection rates (daily) • MRSA, MSSA, ESBL and AmpC (continuously) • Clostridium difficile infections (daily) • Root cause analyses of the above (RCA) • Surgical site infection rates ( continuous rolling programme for THR and

TKR) • Bacteraemias • Antibiotic usage and compliance with the policies • Audit results (on a monthly basis) • Hand hygiene compliance audit results • Environmental cleanliness with the housekeeping managers • Outbreaks and clusters of infectious illnesses • Training and education sessions and their attendance • Policy update programme • IPCLP programme and performance • Emergence of resistance and new infections • Compliance with Care Quality Commission (CQC) Outcome 8 (Code of

Practice for health and adult social care on the prevention and control of infections and related guidance

8.0 TRUST BOARD ASSURANCE

The Trust Board must have the following in place: • a designated non-executive Infection Prevention and Control Champion • Infection Prevention and Control Annual Report • Regular up dates from the DIPC at each Trust Board meeting

9.0 REPORTING TO THE STAFF AND PUBLIC

• Quarterly reporting of: outbreaks and serious incidents requiring investigation, MRSA bacteraemia and C.diff serious infection RCAs to the Clinical Governance Committees in Medicine, Surgery, Family services and Clinical and Diagnostics.

• Quarterly reports to all clinical staff and clinical managers on healthcare associated infections via the IPCC minutes.

• Quarterly reports on MRSA, C.diff, bacteraemia infections and hand hygiene compliance will be presented at the IPCC.

• Divisional leads to take information to Divisional Risk Management & Governance meetings.

• A formal annual report to the board of directors


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• Update information e.g. new policies and audit results will be presented in the Infection Prevention & Control Newsletter.

• Information leaflets on hospital acquired infections for patients and visitors available in paper format and from the Trust WEHCT website

• Information on the Trust web site and intranet includes the Infection Prevention & Control policies.

10 NATIONAL REPORTING TO THE HEALTH PROTECTION UNIT, PCT, SHA AND DEPARTMENT OF HEALTH

• All MSSA, MRSA, ESBL bacteraemias and Clostridium difficile infections are reported to the Health Protection Unit, as per the recommendations, electronically using an enhanced surveillance system. Also reported to the PCT, Strategic Health Authority (SHA) and the Department of Health. Also refer to CP021 Surveillance Policy

• Surgical site infections are reported as per the national scheme and information fed back internally

• Outbreaks and incidents are reported as serious incidents requiring investigation (SIRIs) including patient deaths associated with HCAIs to the SHA and HPU using the standard route.

• The IPCT has responsibility for increasing reporting in line with new mandatory requirements as and when requested by the PCT or any other authority

11 MONITORING THE COMPLIANCE, PERFORMANCE AND

EFFECTIVENES OF INFECTION PREVENTION & CONTROL

• There is a regular programme of audits, led by the DIPC and co-ordinated by the IPCT, which are reported to the IPCC e.g. Hand Hygiene, use of Isolation facilities, IPC policy compliance, High Impact Interventions.

• Divisional audits are reported via the divisions to the IPCC and Risk Management & Governance Committee.

• Alert organism surveillance and trends are reported to the IPCC. • Mandatory surveillance is reported to the IPCC, divisions and Trust

Board. • SIRIs (Infection) are discussed at IPCC and reported to the Risk

Management and Governance Committee, Health Protection Unit and Strategic Health Authority.

• Training and education attendance is monitored by the Education Centre and reported to individual managers, the IPCC and collectively to the Risk Management and Governance Committee.

• Antibiotic usage is monitored and audited by the Antibiotic Pharmacist and reported to the IPCC and Drugs and Therapeutics Committee.


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• Bi-monthly reports on infection prevention and control and surveillance are taken by the DIPC to the Trust Board as part of the quality performance report.

• Programme of environmental and cleanliness walk rounds

12.0 STAFF TRAINING

• Infection prevention and control training on basic principles is part of the Trust wide mandatory training scheme for all staff and is monitored via attendance records. Please also refer to CP072 Training Policy for Employees of WEHCT in Infection Control and OP049 Learning and Development Policy

• Training is provided for all staff at induction • Training is provided for all staff at annual update • Antibiotic and infection prevention and control audits and updates are

made quarterly to the Infection Prevention and Control Committee and sent to every clinical team and ward

• Specialty based training is offered via divisional meetings on an ongoing basis.

• The IPCLPs participate in a specialist programme of on going training. • It is the responsibility of individuals and their line managers to ensure

attendance at training. The Training Department feedback non attendance to line managers and it is their responsibility to follow up non attenders and ensure their subsequent attendance.

• E-learning for infection prevention and control is an acceptable alternative on alternate years once face to face induction is completed. E learning is accompanied by certification which can be used in evidence at appraisal.

13.0 RESPONSIBILITIES OF PERSONNEL

13.1 The Chief Executive is accountable for establishing and maintaining an adequately resourced Infection Prevention and Control Team and arrangements throughout the Trust.

13.2 The DIPC is the lead Executive for IPC within the Trust but may delegate

the daily management of the IPCT to the Infection Prevention and Control Doctor. The DIPC remains in regular contact with the IPCT.

13.3 The Chief Nurse has professional responsibility for the IPCNs who are accountable jointly to her/him and the Infection Prevention & Control Doctor.


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13.4 Lead nurses/modern matrons have a responsibility to provide staff the time to attend infection prevention and control training sessions and link

practitioner meetings, to assist the ward manager and risk co-ordinator to complete the RCAs for patients with infection control issues and to support ward managers and ward staff to challenge others poor practice. 13.5 Ward manager/ department managers are to act as positive role models

to promote good infection prevention and control practices within their ward/department. They are to nominate an IPCLP and support him/her in his/her ward based activities of teaching and audit. They are to facilitate the completion of all Infection Prevention and Control audits carried out within their area.

13.6 All healthcare workers have a duty to act on and report at the earliest opportunity infection that may be deemed infectious to others i.e. communicable/notifiable disease or resistant organisms (a patient in hospital cannot be held liable for introducing infection or spreading it within the hospital environment, but the Trust has a liability to provide safe premises). 13.7 All healthcare workers have a duty of care to adhere to all Trust policies and

protocols applicable to infection prevention & control as stated in their job descriptions.

13.8 All Trust staff have a duty to ensure that visitors, contractors locum and

agency staff to the hospital are made aware of the Trust Infection Prevention and Control Polices by producing those sections relevant to their visit or area of work.

14 WHEN SHOULD HEALTHCARE STAFF CONTACT THE INFECTION PREVENTION & CONTROL TEAM 14.1 When you know or suspect that any patients or staff have :

• MRSA • Clostridium difficile • Chicken pox/shingles • Diarrhoea and vomiting that cannot be explained by the patient’s clinical

condition • Legionnaires disease • Scabies or other human parasites • Symptoms of unexplained infection, and a history of foreign travel • Any other actual or suspected infection, which you feel, we should know

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• Patients diagnosed with or have a differential diagnosis of Transmissible Spongiform Encephalopathies (TSE) or Creutzfeldt Jakob disease (CJD).

14.2 If you think a patient has a notifiable disease (see CP022 the Isolation and Infectious Disease Policy for further details) the doctor must report this directly to the Health Protection Unit (HPU).

14.3 Also contact infection control if:

• Any increase in the number of infections is noted or suspected • You suspect that infections maybe connected • Any patient from another healthcare provider with an infection-related

problem is admitted or transferred to your area. • Purchasing new equipment for ward areas or departments • If your ward/department/work area is planning refurbishment/decoration

14.4 If you have any other queries relating to the prevention and control of

infection, then contact the Infection Prevention and Control Team. See Appendix 1 for contact details.

15.0 DEFINITIONS AND ABBREVIATIONS IPCN – Infection Prevention and Control Nurse IPCT – Infection Prevention & Control Team IPC doctor or IPCD – Infection Prevention and Control Doctor IPCT Infection Prevention & Control team DIPC – Director of Infection Prevention and Control IPCC – Infection Prevention & Control Committee HCAI- Healthcare associated infection Healthcare-Associated Infections (HCAI) are those infections that develop as a direct result of any contact in a healthcare setting. They occur in hospitals and in the community healthcare facilities; and affect both patients and healthcare workers MRSA – methicillin resistant Staphylococcus aureus is used to describe those examples of this organism that are resistant to commonly used antibiotics. Methicillin was an antibiotic used many years ago to treat patients with Staphylococcus aureus infections. MSSA –stands for methicillin (an antibiotic) Sensitive Staphylococcus aureus as opposed to MRSA which is Methicillin (and others) Resistant. ESBL – extended spectrum beta lactamase producing organism which are enzymes that have developed a resistance to antibiotics like penicillin. C.diff –Clostridium difficile infection is the most important cause of hospital-acquired diarrhoea. Clostridium difficile is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants. When certain antibiotics


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disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness. TSE – Transmissible Spongiform Encephalopathy’s Transmissible Spongiform Encephalopathies (TSE’s) or prion diseases are a group of rare, transmissible, and fatal, brain diseases, of which probably the most well-known are Bovine Spongiform Encephalopathy (BSE) in cattle and Creutzfeldt-Jakob Disease (CJD) in humans.CJD - Creutzfeldt Jakob disease CADS – clinical and diagnostic services. A division of the Trust which includes pathology and radiology departments. CSSD manager – Central Sterile Services Department manager PCT- Primary care Trust GP – General Practitioner NHS – National Health Service HPU- Health Protection Unit SHA – Strategic Health Authority RCA- root cause analysis THR – total hip replacement TKR – total knee replacement 16 REFERENCES 1. Haley R. W., Culver D. H., White J. W., et al. The efficiency of infection

surveillance and control programmes in preventing nosocomial infections in US hospitals. American Journal of Epidemiology 1985; 121: 182-205.

2. HSE. HSE 2000/002. The Management and Control of Hospital Infection 3. Association of Medical Microbiologists, 1996: Model Job Description for an

Infection Control Doctor. 4. Infection Control Nurse Association 1996. Competencies for an Infection

Control Nurse.

5. Hospital Infection Society & Infection Control Nurses Association (1996) The Third Prevalence Survey of HCAIs in Acute Hospitals- Results for England

6. Winning ways: working together to reduce healthcare associated

infections. CMO. Dec 2003 7. Hospital Infection Society and Infection Control Nurses Association (2006)

3rd National Prevalence Survey of Healthcare Associated infection in England 2006.


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8. NHS Estates (2004) Matrons Charter: an action plan for cleaner hospitals. Department of Health

9. The Health Act 2008: Code of practice for the prevention and control of

healthcare associated infections. DOH 10. Department of Health (2005) Saving Lives: reducing infection,

delivering clean and safe care.


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Appendix 1 – Contacts and Telephone Numbers Dr Matthew S Dryden IPC Doctor 01962 824451

Hospital Bleep 178 or via switchboard

Dr Roberta Parnaby IPC Doctor 01962 824334

Hospital Bleep 178 Or via switchboard Dr Kordo Saeed IPC Doctor 01962 825927

Hospital Bleep 178 Or via switchboard

Infection Prevention & Control Nurse 01962 825170 Hospital Bleep 177/194 Antibiotic pharmacist 01962 824693

Hospital Bleep 396


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Appendix 2 – Responsibilities of the Infection Prevention & Control Committee The committee will:

• Meet not less than quarterly • Report formally to the Trust Board annually • Be chaired by a Consultant • Keep the membership and terms of reference under review and in

accordance with Clinical Governance arrangements • Monitor the Trust’s compliance with the infection control aspects of

Standards for Better Health (Care Quality Commission - CQC) • Expect that the members unable to attend will send a deputy • Feed into the Trust divisional governance meetings • Circulate the IPCC minutes widely to the relevant Trust committees, senior

medical and nursing staff, HPU, DIPC of the local PCT and Hampshire Partnership Trust

• Advise and support the IPCT. • Advise on, ratify and monitor the implementation of infection prevention and

control policies, procedures and guidelines. • Endorse the targeted surveillance of infection prevention and control

programme developed by the IPCT, and agree on objectives and priorities in this area.

• Promote and facilitate education and the application of evidence based practice in relation to infection prevention and control

• Receive, consider and endorse the annual report and annual programme which will be sent to the Trust board.

• Review the progress of the Annual programme, assist in its effective implementation and review the final results.

• Develop and review priorities and strategies in relation to infection prevention and control ensuring most effective utilisation of resources.

• Draw the attention of the Chief Executive and Risk Management and Governance Committee to any serious problems or hazards relating to infection control

• Discuss and co-ordinate matters relating to outbreaks of infection in the Trust premises and make recommendations to address shortcomings and avoid recurrences

• Discuss, evaluate and action initiatives and developments relating to infection prevention and control and ensure matters are taken forward at a local level.


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Appendix 3 Guidance regarding Infection Prevention and Control Policies The Health Act 2006 Code of practice for the prevention and control of healthcare associated infections states ‘ An NHS body must, in relation of preventing and controlling the risks of HCAIs, have in place the appropriate core policies concerning the matters mentioned in paragraphs (a) to (l) below: The appropriate core polices are: • in the case of an acute trust, all of them:

a. Standard (universal) infection control precautions b. Aseptic technique c. Major outbreaks of communicable disease d. Isolation of patients e. Safe handling and disposal of sharps f. Prevention of occupational exposure to blood-borne viruses (BBVs)

including prevention of sharps injuries g. Management of occupational exposure to BBVs and post-exposure

prophylaxis h. Closure of wards, department and premises to new admissions i. Disinfection policy j. Antimicrobial prescribing k. Reporting HCAIs to the Health Protection Unit (HPU) as directed by the

Department of Health. This includes a mandatory requirement for the trust’s chief executive to report all cases of methicillin sensitive Staphylococcus aureus bacteraemia and cases of Clostridium difficile infection in patients aged 2 years or older.

l. Control of infection with specific alert organisms, taking account of local epidemiology and risk assessment. These infections must include, as a minimum, MRSA, Clostridium difficile infection and transmissible spongiform encephalopathies. ‘


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Appendix 4 - Equality Impact Assessment Tool To be completed and attached to any controlled document when submitted to the appropriate committee for consideration and approval.

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

• Race No

• Ethnic origins (including gypsies and travellers)

No

• Nationality No

• Gender No

• Culture No

• Religion or belief No

• Sexual orientation including lesbian, gay and bisexual people

No

• Age No

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

No

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? No

6. What alternatives are there to achieving the policy/guidance without the impact?

No

7. Can we reduce the impact by taking different action?

No

If you have identified a potential discriminatory impact of this procedural document, please refer it to the Head of Corporate Services, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact: Governance and Compliance Manager 01962 825376