INFECTION CONTROL AND PREVENTION STRATEGY AND ACTION PLAN

INFECTION CONTROL AND PREVENTION STRATEGY AND ACTION PLAN ORIGINATOR Control of Infection DATE April 2005 APPROVED BY Trust Board Policy ID: 281 DATE OF REVIEW April 2008

BRO MORGANNWG NHS TRUST INFECTION CONTROL AND PREVENTION STRATEGY Introduction This strategy aims to support the reduction and control of hospital acquired infections. Healthcare associated infections continue to cause substantial patient morbidity and cost to the health service. National surveys suggest that 9% of inpatients have a hospital-associated infection at anytime costing the NHS as much as 1 billion a year with around 15% preventable through better application of good practice (NAO Report 2000). The Trust Infection Control and Prevention Strategy and Action Plan has been developed in response to the Welsh Assembly Government Healthcare Associated Infections A Strategy for Hospitals in Wales issued in July 2004. The WAG strategy is primarily aimed at reducing healthcare associated infections in acute hospitals. As a provider of integrated health care services the Trust strategy will also be relevant to primary and community care although specific Welsh Assembly Government strategy directives will be issued some time in the future. Background Unfortunately the treatment and care of patients in hospital may sometimes be complicated by the development of infection. The factors critical to the control and reduction of infections include sound hygiene practices, environmental cleanliness, effective methods for disinfection and sterilisation, and the controlled use of antibiotics. Incorporation of these elements into clinical practice must be supported by the continued education and training of staff to ensure good practice. A robust audit and surveillance programme to help to inform on progress must be in place. It is also vital that Infection control specialists with responsibility for helping to develop Trust strategy are supported by and support the relevant Management teams. Indeed Trust Management will have responsibility for ensuring that adequate resources are provided to enable the efficient and timely delivery of an infection control service. The Prevention and Control of infection is therefore acknowledged as a major challenge and priority for the Trust 2

Strategic objectives All staff will understand the impact of infection and infection control practices to enable them to discharge their personal responsibilities to patients, other staff, visitors and themselves. Patients will be treated in physical environments that minimise the risk of infection. Infection Control programmes must be supported by adequately resourced specialist infection control staff with sufficient skill mix to meet the needs of the Trust s infection control plan. The Trust will adopt comprehensive surveillance and audit programmes to monitor and direct their infection control programmes. Programmes will be based upon local need as directed by the Trust infection control plan and programme but will adopt national programmes as they are developed and agreed by the NHS Wales Management Board. Reduction in infection rates will form part of Trust programmes and strategies. This will be embedded within overall Trust management schemes and will have links to clinical governance, risk management, performance management and the Balanced Scorecard. The Trust will develop systems to ensure effective recording, analysis, sharing and access to their own data, and access to information sources appropriate to their needs for managing infection in their Trust. How these Strategic Objectives will be achieved National Standards that are up-to-date and evidence based will be adopted to ensure consistent and effective infection control practice across the Trust and Wales. Infection control will be embedded as a core item of the management agenda and accountabilities of all staff and managers (as appropriate to their function). Specialist (all Wales) epidemiological support will be available to Trust infection control teams as required, to support their infection control programmes. Effective training schemes will be available to meet the needs of all staff. The schemes will cover undergraduate, pre-registration, in-service (NHS and non-nhs), post-registration (both generalist and specialist) staff and include continuing professional development. 3

Structure of the Strategy This strategy builds on Improving Health in Wales and aims to support the reduction in healthcare associated infection. The strategy focuses on six main areas: Standards Infrastructure and organisation Training and education Surveillance and audit Interventions and development of performance indicators Communication Strategic Intent Infection control must be everyone s responsibility, from clinicians, cleaners and ancillary staff to patients and relatives. A key challenge for the prevention and control of healthcare associated infections is to ensure that procedures are in place to reduce the risk of acquiring such infections. The purpose of this strategy is to provide clarity regarding the leadership and direction for the management of the Trusts Infection Control and Prevention agenda which ultimately aims for a reduction of HAI rates. This strategy should be considered alongside other Trust strategies, in particular, the Clinical Governance and risk Management Strategies. This strategy will:! Raise the profile of infection control and prevention throughout the Trust! Provide direction for all staff.! Identify priorities for improvement within a framework of clinical governance.! Provide the foundation for development, implementation and monitoring of an action plan.! Identify challenges and constraints and offer solutions! Support the reporting and accountability process. Accountability and Responsibilities The Chief Executive is accountable for ensuring that systems are in place for monitoring the quality of clinical practice and for assuring the Trust Board that care is being delivered to patients humanely, safely and effectively by staff who remain at the forefront of their profession (Bro-Morgannwg NHS Trust Clinical Governance Strategy 2003). Within the current organisational structure, the Chief Executive delegates responsibility for particular elements of the infection control agenda to the following Executive Directors: 4

The Medical Director and the Executive Director of Nursing is responsible for the implementation of Infection Control and Prevention strategy and Implementation Plan. The Deputy Chief Executive is responsible for corporate assurance, which includes clinical and non-clinical risk. The Director of Planning is responsible for ensuring that all Trust contracts reflect infection control and prevention measures. The Director of Information Management is leading on the development and implementation of the strategy to support the information needs of staff and patients. Organisational Arrangements - Corporate The Trust Board is ultimately responsible for ensuring that patients receive safe standards of care and that clinical quality is being achieved. The Trust has a well-established Infection Control chaired by a Consultant Microbiologist. The role of this includes advising the Trust on the ways of providing a managed environment that focuses on reducing healthcare associated infection rates across the Trust. In addition the is responsible for overseeing the Infection Control and Prevention Strategy and Action Plan. The currently meets quarterly and reports to the Management Executive via the Management Executive leads for Infection Control. Infection control and prevention forms part of the clinical governance report to the Trust Board. Organisational Arrangements - Directorate Each of the 10 Clinical Directorates has a representative on the Trust Infection Control. The Directorates will appoint a Clinical Lead for Infection Control and Prevention with responsibility for ensuring that the infection control agenda is prioritised and managed effectively at an operational level. Accountability for Infection Control at Directorate level will lie with a named individual within that Directorate. Reporting processes will need to be strengthened in order that the can be assured that Directorates are managing their local agendas in line with the Trust Strategy. The following will support local management and ensure standardisation across the Trust: - 1. Where appropriate and in parallel with corporate priorities the Infection Control will identify and agree Directorate priorities from the implementation plan. 2. Reporting on infection control will be a key feature of Directorate performance reviews. 5

Organisational Arrangements Infection Control Team The Trust Infection Control Team has primary responsibility for advising on aspects of the surveillance, prevention and control of infection in hospital. The Infection Control Team for the Trust comprises of two Infection Control Doctors and three Infection Control Nurses. In addition 3 further Consultant Microbiologists provide infection control advice as required on a day to day basis. The Team is responsible for advising on the development, implementation and monitoring of all aspects of infection control and prevention. This is managed through the annual work programme, which is approved and monitored by the Infection Control. The Infection Control Team is supported by the microbiology laboratories at the Princess of Wales Hospital for the Princess of Wales Hospital and affiliated sites. The NPHS microbiology laboratory at Singleton Hospital provides the service for the Neath Port Talbot Hospital and its affiliated sites.. Information technology and Communication Good information management support is essential for efficient working in infection control. The Trust will undertake a baseline assessment of current information systems to support the following: - Gathering, recording, analysing and disseminating data for surveillance purposes; Improving access to clinical information Tracking patient locations Assessing impact of staff activity on infection outcomes Deriving proxies for the effectiveness of infection control management Dissemination/availability of results Monitoring antibiotic resistance Monitoring antibiotic prescribing practice Facilitating communication and making available updates on policies and guidelines: Gaining access to expert advice Developing an intranet based education and training programme Developing an Infection Control and Prevention intranet website 6

Feedback of specific local infection rates to clinical staff is vital in engaging them in reviewing and changing their practice. Previously where there may have been an absence of ownership and open access to data, hospital acquired infection was perceived as a problem for the infection control team to deal with, and consequently barriers to effective infection control practices existed. The new strategy will allow for the Directorates to fully embrace infection control and prevention issues and allow ownership and direction of issues identified. This assessment will take into account the utilisation and compatibility of the current databases supporting the infection agenda. Training and Education The Welsh Assembly Government Strategy places strong emphasis on the need for all health care staff to understand and discharge their roles and responsibilities in relation to infection control within the clinical governance and risk management framework. Ensuring effective training schemes to support the objectives contained within the various policy documents is critical for achieving success. The All Wales Strategy timescale for the development of a training programme is 2006. In order to support the implementation of the Trust s Strategy a training programme aimed at developing infection control expertise to all levels of staff will be a key priority for the Trust. The focus of the programme will be to give responsibility for in-service training and instruction at Ward and Directorate level. Surveillance and Audit Good, accurate and meaningful information and data to plan service delivery, evaluate progress and demonstrate improvements is an essential requirement of the infection control agenda. Infection control surveillance data plays a central role in providing the information needed to underpin strategic objectives as well as informing priorities and focus for day to day operations. Infection reduction programmes can only be demonstrated as being effective if accurate rates of infection are known. Incorporation of an effective surveillance programme with regular feedback of results to clinical staff is recognised as crucial to the development of action plans to facilitate reductions in the incidence of healthcare associated infections. Clinical Directorates, in partnership with the Infection Control Teams will decide upon appropriate surveillance programs. The Directorates will be responsible for the implementation of surveillance with close collaboration and support from the Infection Control Team. Adequate staffing and good management arrangements will be needed to ensure success and the Trust will review the resources available to support the surveillance programme. The Infection Control Team will, alongside the Directorate leads for Infection Control, 7

review the results of the surveillance programs on a regular basis and draw up action plans aimed at reducing the level of hospital acquired infection. Clinical audit provides an important tool to monitor the implementation of policies and operation performance. It can also provide insight into problems highlighted by surveillance. Infection control audit will need to be strengthened and included as part of the Trust s programme of clinical audit. The Infection Control Team will work closely with Directorates to advise and agree on the topics and priorities for audit. Environment of Care There is growing recognition of a relationship between hospital cleanliness and infection. The NHS Plan placed greater emphasis on getting the basics right and that patients should be able to receive high quality care in clean, tidy and welcoming surroundings. The Clean Hospital Programme was introduced and NHS Estates have published National Standards of Cleanliness. The Trust is making progress towards the adoption of these national standards, which are providing a structured approach to defining environmental hygiene requirements that will link in with this strategy. The responsibility for managing the environment of care to ensure high standards of hygiene and maintenance is achieved is a key role of the Ward/Departmental Manager. Support from Corporate Directorates e.g. Estates Department is essential for ensuring that the fabric of the environment is suitable for meeting the needs of patients, visitors and staff. It is essential that audits of ward cleanliness are reviewed with the Infection control team on a regular basis and that the infection control team independently audit ward cleanliness on a regular basis. Any plans for refurbishment, new builds, theatre maintenance, etc must be brought to the attention of the Infection Control team at the first stage of planning. Reporting Monitoring The achievement of measurable improvements in infection rates will need to be underpinned by setting, implementing and monitoring national and local standards. In order to target activities to improve practices health professionals, support staff, managers and the public need to know how they are doing against these agreed standards. Robust comparable information on infection rates, costs and patient outcomes is needed. The Welsh Risk Pool and National Cleanliness Standards form the current framework for infection control and hygiene management. In addition the Standards for NHS Care and Treatment in Wales will be added to this framework from April 2005. Corporate and Directorate specific Infection Control Performance Indicators in the form of Critical Success Factors will be developed and used to demonstrate robust outcome measures. The development of these indicators 8

will seek to ensure a reduction in infection rates across the Trust. These will be monitored through the Trusts Performance Management framework. External reporting Progress on the implementation of this strategy and Action plan will be reported via the WAG Regional Office Reviews as part of the Clinical Governance Reporting process. Health Inspectorate Wales will review and assess the Trust as part of their routine programme of inspections. Implementation of this Strategy Despite the increasing profile of hospital-acquired infection and the publication of guidelines on measures required to contain the problem, there continues to be non-compliance with good infection control practices. The next section of this strategy will focus on the action plan. Objectives and time-scales are included within each section of the action plan. In order for this strategy to be implemented it is essential for it to be owned by all staff. Good clinical and managerial leadership at all levels, clarity of roles and responsibilities and multidisciplinary team working will be key to success. Some objectives will be dependent on resources and will therefore need to be prioritised against competing objectives. Others may be achieved by changing working practices as part of the modernisation agenda. 9

Charlette Middlemiss/Louise Wooster Page 1 19/04/2005 January 2005 Infection Control Action Plan January 2005 Objective Monitoring Action Target Progress Dates Lead Green Amber Red National Standards Strategic objective National standards that are up to date and evidence based will be adopted to ensure consistent and effective infection control practice Develop a Trust Infection control and Prevention Strategy and Action Plan Develop policy for managing the implementation of the national clean your hands campaign. Develop system to increase public awareness and compliance with good infection control practice (Paul Jones/Norma could help). Awaiting WAG Guidance Clinical Gov Infection Control Infection Clinical Control Gov Jan 05 April 05 Ex DoN / MD ICSG ExDoN / SICN Comply with the Statement of Standards for NHS Care and Treatment and current National Cleanliness Standards in operation in Wales relating to Infection Control Work towards improving compliance with WRMS standards which have relevance to infection control - WRP Standard 14: Infection Control - WRP Standard 23: Nutrition & Catering - WRP Standard 30: Medical Infection Control Clinical Gov Clinical Audit & Effectiveness May 06 DCE / ExDoN / MD As per leads for each WRMS standards Objective Monitoring 1

Charlette Middlemiss/Louise Wooster Page 2 19/04/2005 January 2005 Equipment& Devices - WRP Standard 35: Waste Management - WRP Standard 36: Decontamination - Infrastructure and Accountability Strategic objective - All staff will understand the impact of infection control practices to enable them to discharge their personal responsibilities to patients, other staff, visitors and themselves; Infection control must be embedded as a core management agenda and accountabilities of all staff and managers (as appropriate to their function) The Trust will review Management arrangements to ensure clear lines of accountability for all staff in compliance with infection control policies and procedures. Each Directorate (clinical and non clinical) will appoint an Infection Control and Prevention lead with accountability for infection control practice within the Directorate. Each Directorate will develop a job description and job plan concerning the roles and responsibilities of the Infection Control Lead. Each Directorate will determine, in conjunction with the ICT, priorities for action in their area of activity through the Trusts risk assessment process. Develop local Directorate action plans to inform the Trust wide infection control programme Local Directorate plans to inform the T st /Di ecto ate Risk Registe Trust Board Trust Board March 2005 Ex DoN MD ICC CG CG ICC CGC March 05 CD/D Ex DoN/MD CD CD/D CD/D CD/D 2

Charlette Middlemiss/Louise Wooster Page 3 19/04/2005 January 2005 Trust /Directorate Risk Register Each Directorates will have agreed Infection Control and Prevention priorities and critical success factors which will be reported via Directorate Performance Reviews. Directorate Performance Management Clinical Gov March 05 Directorate Leads for Infection Control 3

Charlette Middlemiss/Louise Wooster Page 4 19/04/2005 January 2005 Objective Monitoring Action Directorate based expertise in Infection Control is to be developed Target Dates Lead Green Amber Red DLIC ICN Clarify accountabilities, membership roles and responsibilities of Hospital Infection Control Trust Board March 05 Chair ICC The Trust Board will receive quarterly reports on infection control. Reports will made to WAG Regional Office as part of the clinical governance reporting process. The Trust Performance Management Framework will include high level infection control critical success factors Infection control practices will feature in staff appraisals and job descriptions. Trust Board 05 ExDoN / MD ICC Man Exec Clin Gov Com Mar 05 Jan 06 Directorate leads for Infection Control CD / DCE 4

Charlette Middlemiss/Louise Wooster Page 5 19/04/2005 January 2005 Objective Monitoring Action Specialist Infection Control Support Strategic objective; Infection Control programmes must be supported by adequately resourced specialist infection control staff with sufficient skill mix to meet the Trust s infection control strategy/plan A benchmarking review of the resources supporting the infection Infection Control control team will be carried out. This will identify good practice and provide Clinical Gov updated the basis for recommendations on Infection control staffing and resources Directorate leads for Infection Control will become core members of the Trust s infection control committee A review of the Microbiology Laboratory resources (staff and non staff) required to support the Infection Control Service will be undertaken and recommendations made Establish clear requirements and resources to support information and data for effective management of the infection control agenda at both operational and corporate level within the Trust Develop the Link Nurse role Trust wide. Aug 05 April 05 Mar 05 Target Dates Lead Green Amber Red ICT EXDN ICC CD Dir Pathology ICD Ex Do N MD Dir of IM&T ICN 5

Charlette Middlemiss/Louise Wooster Page 6 19/04/2005 January 2005 Facilities Strategic Objectives; Patients will be treated in physical environments that minimise the risk of infection The Trust will review the current isolation facilities available The Trust will work towards providing the appropriate isolation facilities to meet their needs. 6

Charlette Middlemiss/Louise Wooster Page 7 19/04/2005 January 2005 Training and Education Strategic Objectives; Effective training schemes will be available to meet the needs of all staff. The schemes will cover undergraduate, pre-registration in service(nhs and non NHS), post registration (both generally and specialist) and continuing professional development. Infection control training will be provided to all staff ( including PFI staff ) as part of the Trust induction programme A training and education strategy for infection control will be developed and delivered. This will include priorities, mechanisms for maintaining training records, media for delivering training, audit of training, development of a training programme evaluation and reporting. Multi-disciplinary training group Infection Control Infection Clinical Control Gov On-going DLIC ICT 12 months DLIC ICT 7

Charlette Middlemiss/Louise Wooster Page 8 19/04/2005 January 2005 Surveillance Strategic Objectives; The Trust will adopt a comprehensive surveillance and audit programme to monitor and direct their infection control programmes. The programmes will be based on local need as directed by the Trust infection control plan and programme, but will adopt national programmes as they are developed and agreed by the NHS Wales Management Board. The Trust is to ensure training and education is provided to all staff to meet their needs. Participation in all mandatory national surveillance programmes as they are developed and adapted. Clinical Gov Quarterly MD Current mandatory surveillance participation - Surgical Site Surveillance orthopaedics and caesarean sections - Staphylococcus aureus Bacteraemia - Outbreak reporting - C Difficile Develop robust methods of surveillance programmes for the following; Vascular surgical infections Infections in ITU Central vascular device associated infections Hospital acquired UTIs Hospital acquired RTIs Hospital acquired skin infections Antimicrobial prescribing Clinical Gov Quarterly MD/CD ICC ongoing DLIC CD 8

Charlette Middlemiss/Louise Wooster Page 9 19/04/2005 January 2005 Other laboratory confirmed bacteraemias e.g. glycopeptide resistant enterococci. Clinical Directors in Infection Control will ensure that each Directorate will work towards improving participation in surveillance schemes and compliance with data collection Directorate leads in Infection control will have responsibility for naming personnel to hold the surveillance database. Ownership of the database will lie within the Department/Directorate involved in the surveillance. A system to provide the quarterly results of surveillance schemes to both the Department/Directorates involved and the ICT will be developed and implemented. The ICT will, in conjunction with the Directorates and Directorate leads for Infection Control, identify any areas of concern highlighted by the surveillance programme results and set in place an action plan to address these points. ICC CGC ICC CAEC ICC ICC CGC DLIC IM CD ICT ICD CD DLIC SICN 9

Charlette Middlemiss/Louise Wooster Page 10 19/04/2005 January 2005 Objective Monitoring Action Audit Strategic Objective; To monitor the implementation of policies and operational performance The Directorate leads in Infection Control will, in conjunction with the ICT, identify and prioritise audit projects for incorporation in the annual infection control programme Complete and submit to WAG expression of interest to pilot UK audit tool. Annual audit programmes will include areas relevant to infection control contained within A Statement of Healthcare Standards Standards of NHS Care and Treatment in Wales. CAEC ICC CAEC Sept 05 Target Dates Lead Green Amber Red Directorate Leads in IC ICT 10

Charlette Middlemiss/Louise Wooster Page 11 19/04/2005 January 2005 Interventions and Performance Indicators Strategic Objectives; A reduction in infection rates will form part of the Trust s programmes and strategies. This will be embedded within overall trust management schemes and will have links to clinical governance, risk management, performance management and the Balanced Scorecard. In accordance with WHC2003(43) the Trust will set and register annually with the Healthcare Associated Infection Project team, local priority targets for measurable infection reduction MRSA Strategy Group to be set up to include the development of a MRSA Care Pathway. Review of Bed Management Trust wide Development of robust performance indicators Utilise and develop the National Standards for cleanliness for NHS Trusts in Wales Performance assessment toolkit. ICC CGC ICC CGC DCE GM EXDN CD ICT EXDN MD GM SICN ICD CD 11

Charlette Middlemiss/Louise Wooster Page 12 19/04/2005 January 2005 Objective Monitoring Action Target Dates Lead Green Amber Red Information Technology and Communication Strategic Objectives; Trusts will develop systems to ensure effective data, and access to information sources appropriate to their needs for managing infection in the Trust The Trust will take account of the needs of infection control in the development and implementation of future IM&T programmes The Trust will ensure that appropriate resources are available to provide the ICT with specialist IT tools and software necessary to meet the Standards set by the WAG Establish clear requirements and resources to support information and data for the effective management of the infection control agenda at a corporate and operational level within the Trust. March 05 ExDoN / MD Dir of IM&T 12

Charlette Middlemiss/Louise Wooster Page 13 19/04/2005 January 2005 KEY: ICC Infection Control Team ExDoN Executive Director of Nursing MD Medical Director DCE Deputy Chief Executive DIM&T Director of Information Management ICT Infection Control Team 13