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3.0
EQUALITY IMPACT
The Trust strives to ensure equality of opportunity for all, both as a major
employer and as a provider of health care. This Policy for the Prevention and Control of
Infection has therefore been equality impact assessed by the Infection Control
Committee to ensure fairness and consistency for all those covered by it
regardless of their individual differences.
Version: 3.0
Authorised by: Infection Prevention and Control
Committee
Date authorised: September 9th 2008
Next review date: January 2010
Document author: Angela Hallas
TAMESIDE HOSPITAL NHS FOUNDATION TRUST policy for the prevention and control of infection
Version : 3.0-
INTRODUCTION
An estimated 5,000 patients die as a direct consequence of Health Care Associated
Infection (HAI) every year throughout the NHS.
PURPOSE/RATIONALE/OBJECTIVES
This policy sets out the Trust’s arrangements for the prevention and control of Health
Care Associated Infection. The policy outlines the responsibilities shared by all for
minimising the risk of infection to patients, visitors and staff.
SCOPE
This policy is applicable to all staff, patients (adults and children) and visitors to
Tameside General Hospital.
GUIDELINE STATEMENT
All NHS organisations must comply with The Health Act 2006 Code of Practice for
the Prevention and Control of Healthcare Associated Infections. The code of practice
requires effective prevention and control of Healthcare Associated Infections to be
“embedded into everyday practice and applied consistently by everyone”.
Every clinician has the potential to significantly reduce the risk of infection to their
patients by ensuring that they consistently apply evidence based practice and follow
established guidelines whenever they undertake a clinical procedure.
This policy when applied in conjunction with the Trusts assurance framwork will
ensure organisation compliance with the duties described in the Health Act 2006
Code of Practice.
strive to provide for patients. Infection is a significant cause of harm and can result in
patient suffering , unnecessary pain, anxiety and possible death. Many HCAIs are
avoidable and everyone can contribute to reducing their burden.
Effective prevention and control needs to be embedded in every day practice
(DOH2006). In 2007 the EPIC group (Evidence Based Practice for Infection Control)
noted that standard infection control precautions need to be applied by all health care
practitioners to the care of all patients .
DUTIES
Management Organisation and Environment
Tameside Hospital NHS Foundation Trust will ensure that at all times appropriate
sytems, structures and processess are in place to protect patient, visitors and staff
from the risk of health care associated infection. The Trust Board will commission
and approve an annual programme of work setting out the organisations strategic
objectives for the prevention and control of infection. Delivery of the objectives will be
managed under the clinical governance framework. Responsibilities for the
prevention and control of infection are assigned to key officers as outlined:
Chief Executive
The Chief Executive has overall responsibility and is accountable for ensuring that
there is a managed environment which minimises the risk of infection to patients,
visitors, staff, contractors and all who use the hospital site for any purpose.
The Infection Prevention and Control Team report directly to the Director of Infection
Prevention and Control and are responsible for aspects of surveillance, prevention
and control of infection within the Trust. The Infection Prevention and Control Team
are responsible for the implementation of the Trust’s Infection Prevention/ Control
programme and for the development and dissemination of policies, guidelines and
procedures.Key functions of the infection control team include:
Microbiology Laboratory
The Microbiology laboratory provides a 24 hour, accredited service for the diagnosis
of infection. The laboratory supports the Infection Control Team by processing
microbilogical specimens , providing immediate notification of “alert” organisms and
by facilitating the collection, interpretation and dissemination of surveillance data.
All Staff
All staff are responsible for following policies, procedures and guidance ( written or
verbal) relating to the prevention and control of infection , at all times. Staff are
responsible for ensuring that they understand the risk of infection associated with
their activity and that they adopt safe practice for their own safety and that of others.
Any member of staff who has concerns about infection risk,suspicions of an outbreak
of infection will discuss their concerns (as a matter of urgency) with the infection
control team. In addtion staff have a responsibility to provide appropriate and
sensitive information to patients and visitors so that they are aware of the risks and
implications of health care associated infections and understand the contribution that
they can make to prevention.
All staff entering the clinical area that have responsibility for direct patient contact will
adopt the ‘bare below the elbows’ dress code.The ‘bare below the elbows’ initiative is
part of the government’s Clean Safe Care strategy which aims to reduce infection
risks by improving hand hygiene
All clinical staff must now wear short sleeves or sleeves rolled up and NO hand or
wrist jewellery (other than a plain metal wedding band).Allied to this is the avoidance
of wearing ties when carrying out clinical activity.
• Any staff who wear their own clothes in the clinical area, must adhere to the
‘bare below the elbows’initiative for the facilitation of hand washing.
• Clothing worn by all staff must be clean and fit for purpose and hands washed
before before and after patient contact.
• Coats etc can either be left in the ward ‘rest room’ or carried , as long as they
are removed whilst hand washing takes place.
This guidance ensures good hand washing and wrist washing,as staff that are bare
below the elbows are not impeded by shirt cuffs or jewellery.
Hand Hygiene
Effective decontamination of the hands is the single most effective way of preventing
the spread of infection in the healthcare setting. Hands must be decontaminated
immediately before each and every episode of direct patient contact/care and after
activity or contact that potentially results in hands becoming contaminated(EPIC2).
Hands should be decontaminated between caring for different patients or between
different care activities for the same patient.
Effective hand hygiene depends on a technique that enables all the surfaces of the
hands to be cleaned and dried thoroughly.
Alcohol handrub/gel
Rubbing the hands with an alcohol handrub or gel is an effective alternative to soap
and water washing. This method should be used whenever the hands are visibly
clean and have not been contaminated by body substances.Alcohol hand rub
should be used by all staff before and after all ‘hands on’ patient contact.
To be effective the alcohol product must come into contact with all the skin surfaces
and the hand should be rubbed together vigorously until the alcohol has evaporated
completely and the hands are dry.
It should be noted that following five applications of alcohol product the hands
will require a soap and water wash.
Handcreams
Regular use of handcream can help to protect the skin on thehands and prevent
cracking and chaffing. It is important that staff have access to good quality hand
cream but this must be in the form of a wall mounted dispenser providing a cream
manufactured to complement soap and alcohol products selected for use within the
Trust.
ring can not be removed , the wearer will ensure that the ring and the skin beneath
are thoroughly cleaned and dried during hand decontamination.
Gloves
Gloves should be worn in accordance with the Trust’s Policy for the selection and
use of gloves.Gloves must be worn as single use items.
Isolation of Patients
It is appropriate in some circumstances to nurse patients in single room isolation. In
such circumstances clinical staff will implement the Isolation Policy under the
guidance and direction of the infection prevention and control team.
The Isolation Policy identifies two distinct types of isolation as follows:
• Source Isolation – the isolation of a patient who may pose a risk of infection to
others
Inoculation Injuries
All staff must be familiar with the procedure to be followed in the event of an
inoculation injury as per policy-Management of Inoculation Injuries.An inoculation
injury includes needlestick and sharps injuries,bites scratches and splashes (body
substances) onto broken skin or mucous membranes membranes.
Following an inoculation injury all staff must attend Accident and Emergency for the
HIV risk assessment on the source to be undertaken. In accordance with the Trust
Policy for all staff attending Accident and Emergency must then attend Occupational
Health to allow for the appropriate follow –up treatment and documentation to be
completed.
All inoculation injuries must be reported to the line manager on duty and through the
incident reporting system to Risk Management.
Linen
Clean Linen
Fouled Linen (contaminated with body substances) and “Infected” Linen (from
a known infected patient)
All foul anf imfected linen is placed into red aliginate (hot water soluble) bags inside
red laundry bags and removed from the ward immediately.
Outbreak of Infection
For the purpose of this policy an outbreak has been defined as two or more cases of
infection which are or appear to be associated in time and place. It should be
acknowledged that in some very special circumstances , a single case of infection
may prompt the implementation of outbreak controls.
Outbreak Investigation
The infection control team are responsible for the investigation of any suspected or
confirmed outbreak of infection and will liase with colleagues in other agencies as
appropriate. On confirmation of suspected outbreak the infection prevention and
control team will implement the Outbreak of Infection Plan
Outbreak Control
All staff will be required to follow the instruction of the infection control team and to
implement such control measures as may be necessary for the protection of
patients,visitors ,staff and the wider community.
Antibiotic Therapy
The contribution of antibiotics in the treatment of serious infections cannot be
underestimated; however the unrestricted administration of antibiotics can lead to the
selection of antibiotic-resistant organisms and can increase the patient’s risk of
Clostridium difficile associated diarrhoea. Such organisms are sometimes associated
with increased morbidity and mortality. It is important to ensure that antibiotics are
prescribed in a way which minimises the risk. Local antibiotic guidelines are provided
and have been designed to enable clinicians to treat common infections effectively
and with the minimum risk of healthcare-associated infections. All prescriptions for
antibiotic therapy must be reviewed after 72 hours to ensure that the prescription is
necessary and appropriate.
Responsibilities for the prevention and control of health care associated infection will
be clearly identified in the job description for all health care workers. Training needs
accountabilities and objectives in relation to infection prevention and control
activities will be identified and discussed during personal development meetings and
will be documented in personal development plans for all employees.
DEFINITIONS
Health Care Associated Infection (HCAI) - infection that is acquired as a result of
contact with the health care system.
Hospital acquired infections - infections that develop in patients 48 hours or more
after admission to hospital.
Community acquired infections - any infection from which the patient was suffering
when they came into hospital or occurs within 48 hours of admission (i.e. acquired in
the community).
Invasive procedures – procedures involving a break in the skin, contact with mucous
membranes, or a body cavity
Body Substances - all secretions produced by the body (especially blood and blood
stained fluids, but also serous fluids, such as pleural or cerebrospinal fluids, and genital
and oral secretions, faeces, sputum etc.) which may contain potentially harmful
organisms.
IMPLEMENTATION
The policy will be displayed on the intranet and within Volume 1 of the Infection
Prevention and Control Manual issued to all wards and departments. The policy will
also form an integral part of the existing Infection Prevention / Control training for all
MONITORING
Compliance with this policy will be monitored by the infection prevention and control
team on behalf of the Infection Prevention and Control Committee. Annual
environmental and practice audits will be undertaken by the Infection Control team
and formal reports will be issued to all managers, clinical leads and departmental
heads. Departmental managers will be required to submit, implement and monitor
remedial action plans where necessary. Clinical divisions report complance via
Clinical Governance Framework reporting structures.
REFERENCES
Department of Health (2006).The Health Act .Code Of Practice For The Prevention
and Control of Healthcare Associated Infections. The Stationary Office .
Pratt,R.J.,Pellowe,C.M.,Wilson,J.A.,
Loveday,H.P.,Harper,P.,Jones,S.R.J.J.,McDougall,C.,Wilcox,M.H.(2007). EPIC2
National Evidence Based Guidelines For Preventing Health Care Associated
Infections in NHS Hospitals In England.
.
APPENDICES
Appendix 1 Equality Impact Assessment Tool
To be completed and attached to any procedural 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
• Nationality No
• Gender No
• Culture No
• Religion or belief No
• Age No
Yes/No Comments
health problems
2. Is there any evidence that some groups are No
affected differently?
3. If you have identified potential No There is no discrimination in
discrimination, are any exceptions valid, this guidance
legal and/or justifiable?
4. Is the impact of the policy/guidance likely to No
be negative?
5. If so can the impact be avoided? N/a
6. What alternatives are there to achieving the N/a
policy/guidance without the impact?
7. Can we reduce the impact by taking N/a
different action?
Appendix 2
REVIEW
This policy will be formally reviewed in January 2010 or earlier depending on the
results of monitoring, or as a result of incidents or recommendations from recognised
National bodies or the introduction/review of legislation.