«Policy Number IC01 Policy Title INFECTION PREVENTION AND CONTROL POLICY Accountable Director Director of Infection Prevention and Control Author Lead ...»
Colonisation Is the term used to describe the presence of germs in or on the body (including wounds), but without any sign of illness or disease. The body is colonised with
many germs the majority of which cause no harm and some are actually beneficial.
Micro-organism Also know as germs. These are bacteria, viruses, fungi or protozoa. They are too small to be seen by the naked eye and can only be seen under a microscope. Most of these are harmless, many keep us healthy e.g. germs in the healthy bowel process vitamins essential to our well-being. Those causing disease are known as pathogens. Like all living things, micro-organisms require food, water, warmth and the correct atmosphere to flourish.
Communicable Disease An infection which is capable of spreading from person to person.
Spread of Infection Is usually spread by one of the following means:Direct Spread Contact with contaminated blood, or body secretions particularly by staff hands that have become contaminated by body to body contact, and by transfusion of contaminated blood.
Indirect Spread Contact with contaminated equipment such as razors or needles.
Airborne Spread Of contaminated skin scales, aerosol spread via droplets from coughing and sneezing.
Vectors Third parties such as cockroaches, fleas, flies, mosquitoes, all harbour infectious agents.
Sequence of Spread:The Organism The source or causative agent The Reservoir The place where the organism normally lives.
Point of Entry Different organisms have different modes of entry, e.g. Salmonella enters through the mouth; Tuberculosis enters through the nose and mouth and then into the lungs.
Point of Exit Salmonella exits the body in faeces; Tuberculosis exits the same way it comes in, through the mouth or nose.
Method of Spread All organisms need a method of getting to the person they will infect or colonise.
Hands play a major part in spreading infection.
Susceptible Host This is the person who will become ill.
10. REFERENCES Antimicrobial Guidelines and Management of Common Infections in Primary Care- Autumn 2012 Ayliffe GAJ Babb T.R, Taylor L.Z,- Hospital Aquired Infection, Principles and Prevention, 3rd Ed, 2001 Bare Below the Elbows- DoH 2010 Clostridium difficile Infection, How to Deal with the Problem (2009) DoH http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolic yandguidance/dh093220 DoH (2006) Screening for MRSA Colonisation PL/CMO/2006/4 The Equality Act, DoH 2010 Evans, B Duggan, W Baker, J Ramsay- Occupational Exposure Surveillance Advisory Group (2007) Heath and Safety Executive (2003) Control of Substances Hazardous to Health Regulations HSE The Health and Social Care Act (2008) DoH http://www.dh.gov.uk/en/publicationsandstatistics/legislation/actsandbills/health andsocialcarebill/index.htm
The Human Rights Act 1998, Section 6, DoH Immunisation Against Infectious Disease- The Green Book- Gov UK National Guidelines for Uniforms and Dress Wear DoH 2001 National Specification for Cleanliness in the NHS 2007 NHS Litigation Authority- Nursing and Midwifery Council The NHS Standards for Cleaning Patient Led Assessment of the Care Environment (2012) PLACE Royal Marsden Clinical Procedures, 8th Ed http://www.royalmarsdenmanual.com/online/toc.asp The World Health Organisation “5 Moments for Hand Hygiene”
Appendix 3 Please phone Infection Prevention and Control immediately whenever you have a positive MRSA or Clostridium difficile result Healthcare Associated Infection (HCAI) – Monthly Surveillance data collection form
• Email this form to Division Lead on last day of the month, even if it is a nil return.
• Division Lead to e-mail Service Data Sheet to Infection Prevention and Control by the 7th of each month.
• Do not send this form direct from ward to infection c
WARNING: It is important that the bag is removed before tumble drying, so if you have a ‘washer -drier’ please make sure it is not on an automatic programme that goes straight to drying as the bag could damage your machine if tumble dried.
It is best to tumble dry and or iron clothes on the hottest setting allowed for the fabric after laundering as this helps to further reduce the amount of bugs, making clothes safer for reuse.
If you require any further advice or information regarding laundering of clothing from hospital please
The Mersey Care NHS Trust Infection Prevention & Control Team Telephone 0151 471 2635
This form is to be completed each month and e-mailed from Ward Manager to Modern Matron Modern Matrons to collate data for their area and send assurance to the DIPC (Director of Nursing) same to be copied to Infection Prevention and Control.
Hand Hygiene Observational audits carried out * Mattress Checks completed as per mattress management tool * Medical Devices Decontamination Checklist completed weekly. * MRSA and C.diff returns completed and sent to service manager Environmental checks carried out to ensure area/ward is clean and in good state of repair *
Infection Prevention and Control Link Practitioner An Infection Prevention and Control link person is Name.
identified for area Date of last attendance at Infection Prevention and Date.
Control Link Practitioner training IPCLP Training cascaded and cascading form from Date.
Training returned to ICT.
Please report any other infection prevention and control issues or concerns identified:
Name Ward Manager _________________________________________________
Prior to Inspection, Servicing, Repair, Condemning or Return of Medical Devices and Other Equipment
Make and Description of Equipment:
Tick box A if applicable. Otherwise complete all parts of B, providing further information as requested or appropriate A. This equipment/item has not been used or been in contact with blood, other body fluids, respired gases, or pathological samples. It has been cleaned in preparation for inspection, servicing, repair, condemning or transportation.
Not all infected service users display typical symptoms; therefore some infections (including blood borne viral infections) may not have been identified at time of death.
Note 2: In accordance with health and safety law, and the information provided in the Health Service Advisory Committee Guidance, Safe Working and the Prevention of Infection in the Mortuary and Post Mortem Room.
Controlling the risks of infection at work from human remains. HSE 06/2005 Appendix 8 Page 82 of 94 Infection Prevention and Control Policy Hand Hygiene Instructional poster
Issues identified / Action to be taken Time-Scale Co-ordination of Implementation 1 Week The Director of Infection Prevention and Control will arrange for the policy to be distributed Trust wide via Division Managers.
Encouraging Staff This policy is applicable to service users and staff.
Involving Service Users and Carers All staff should be aware of where this All staff should sign a form when they have read the Policy. 4 Weeks policy can be found.
Communication This policy is in line with the Health and Social Care Act 2008. CQC Essential Standards for Quality & Safety (2009), NHSLA requirements and government guidance.
Key Policy Issues:
• Transmission of infection.
• Hand Hygiene Policy – Decontamination of hands.
• Decontamination of the Environment, Cleaning, Body Fluid Spillages, Laundry and Clinical Waste.
• Standard Principles for the use of Personal Protective Equipment.
• Infectious Diseases A-Z including Clostridium difficile, Meningitis, MRSA and TB Page 87 of 94 Policies.
• Isolation Policy
• Surveillance Policy.
• Major Outbreak Policy/ Management of Outbreak.
• Blood Borne Virus Policy (HIV, Hepatitis B and Hepatitis C).
• Safe Use and Disposal of Sharps.
Training Staff must read this policy and sign IPCLP’s are required to attend all mandatory training that they have read it. sessions, and Managers are expected to facilitate the Infection Prevention and Control Link cascade training following attendance at the sessions for Practitioner training will be organised the rest of the staff group.
to reinforce the key issues of minimising the risks.
Resources No significant resource implications has been associated with this policy Securing and Sustaining Change Managers must keep a record that staff have signed that they have read this policy and know where it can be accessed.
Managers must ensure that any staff who are off sick or on annual leave when this policy is distributed will read and sign that they have read the policy on their return to work.
Managers will keep a record of staff signatures.
Managers will identify an Infection Prevention and Control Link Practitioner for their ward or department. There will be clear Page 88 of 94 Infection Prevention and Control Policy identification of Infection Prevention and Control Link Practitioners across the trust and this information will be held by the Infection Prevention and Control Team.
Evaluating The Infection Prevention and Control Team have drawn up an audit tool with the audit department which will audit compliance to aspects of the policy. 24 Months Audit will be carried out by the Infection Prevention and Control Team.
Equality and Human Rights Analysis Title: Infection Prevention and Control Policy Area covered: Corporate What are the intended outcomes of this work?
Seeks to minimise the risk of infection to patients, staff, and visitors Who will be affected?
Service user, Staff, Public.
Evidence What evidence have you considered?
Previous and Proposed policy documents.
Leaflets should be offered in alternative formats on request.
Disability inc. learning disability This policy is offered in alternative formats on request Sex This policy does not adversely impact on sex Race This policy is offered in other languages on request.
Leaflets should be offered in other languages on request Age This policy does not adversely impact on age Gender reassignment (including transgender) This policy does not adversely impact on transgender Sexual orientation This policy does not adversely impact on sexual orientation Religion or belief This policy ensures the provision of over sleeves for religious purposed.
Pregnancy and maternity This policy does not adversely impact on pregnancy and maternity Carers This policy aims to protect all people accessing the Trust Other identified groups Cross cutting Not applicable
Right to a fair trial (Article 6) This article is not engaged Right to private and family This article is not engaged life (Article 8) Right of freedom of religion This article is not engaged or belief (Article 9) Right to freedom of This article is not engaged expression Note: this does not include insulting language such as racism (Article 10)
Summary of Analysis Eliminate discrimination, harassment and victimisation No evidence of the above Advance equality of opportunity This policy is aimed equally at all groups Promote good relations between groups Not applicable What is the overall impact?
Addressing the impact on equalities Action planning for improvement See Action Plan
For the record
Name of persons who carried out this assessment (Min of 3 ):
Diane Peel Barbara Rafferty Steven Jeffrey
Date assessment completed:
16th December 2013 Name of responsible Director: Director of Infection Prevention and Control
Date assessment was signed:
16th December 2013