INFECTION CONTROL NURSING SERVICE by dfhrf555fcg

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									INFECTION CONTROL NURSING SERVICE


           Provided to:
  HEART of BIRMINGHAM TEACHING
      PRIMARY CARE TRUST




         ANNUAL REPORT
          JANUARY 2004
                                             CONTENTS


1.      Introduction

2.      Service Provision

3.      Clinical Advice

4.      Education and Training

        a)       Educational input
        b)       Link Nurse Course
        c)       Infection Control Interest Group
        d)       Regional Infection Control Study Day
        e)       Nursing Auxillary Study Day
        f)       Handwashing Roadshow

5.      Infection Control Policy and Procedure Manual

6.      Audit - Monitoring

7.      MRSA

8.      Outbreaks

9.      Committees/Groups

10      Controls Assurance

Conclusion

Appendix 1               Review Dates for Infection Control policies
Appendix 2               Control of Infection and Decontamination Committee
                         Terms of Reference
Appendix 3               Control of Infection work programme 2003-2004-01-29
Appendix 4               Control of Infection Controls Assurance Action plan




HOBtPCT Control of Infection Annual Report      2
1.      Introduction

        The importance of infection control in Health Care provision has been
        extensively recognised, both locally and nationally, which has resulted in the development of many
        new documents.

        These have included the House of Lords Report on Antimicrobial Resistance
        where it was recommended that Infection Control and healthcare hygiene are put at the heart of
        healthcare management. The socio-economic burden of HAI has been reviewed by the Public
        Health Laboratory Service, PHLS (1999), identifying that ‘HAI’s impose a substantial burden on
        the secondary and primary health care sectors, on infected patients and their informal carers’.

        The Department of Health has recognised the need to ensure that Infection
        Control Service Provision meets recognised National Standards. As a result
        The Controls Assurance (CA) Infection Control and Decontamination Standards have been
        published. The CAs set standards for action for the NHS to strengthen prevention and control of
        infection, secure appropriate health care services for patients with infections, improve surveillance
        of healthcare acquired infection and monitor and optimise antimicrobial prescribing. These
        directives have considerable implications on clinical practice and service demands.

        The recently published document from the PHLS, ‘Infection Control in the Community Study’,
        (2002), has recommended that each PCT should have their own Community Infection Control
        Nurse to meet these demands. The study provides indicative standards in line with The Controls
        Assurance documents and the ‘Getting ahead of the Curve’, DOH (2001) recommendations. The
        new ‘Winning Ways’ DOH (2003) document further enforces the position of Infection Control
        advice and provision.

        As a consequence the demands being placed upon the Infection Control Team
        are increasing. The Infection Control Nurses continue to provide a service that
        will ultimately improve the quality of patient care and the occupational health of staff.




HOBtPCT Control of Infection Annual Report             3
2.      Service Provision

        The Infection Control Nursing Service provides advice, education, audit, outbreak management,
        capital planning, etc to the four Birmingham Primary Care Trusts, (2.00wte Infection Control
        Nurse Specialists).

        An existing Service Level Agreement (SLA) is in operation which is currently being reviewed. The
        Infection Control Nursing Service recommend that at least the standards in the PHLS (2002)
        publication, one ICN per PCT, are met.

        Currently the SLA does not encompass General Practitioners and their Practice Nurse staff, this
        represents an area of potential risk for the Trust.


3.      Clinical Advice

        On-going advice and support for all staff has been provided to all areas within
        the Birmingham Primary Care Trusts. This service continues to be fully utilised by all members
        and disciplines of health care teams. The demand for advice and support is ever increasing.
        However the issue of a substantial SLA to meet the increased demand of GPs and Practice Nurses
        has yet to be established.

        The Infection Control Nurses are easily accessible by telephone, mobile phone,
        and email and maintain a high profile within the clinical areas.

        Other advice that represents considerable input by the ICNs is Capital Planning. This work,
        ongoing and always time-consuming, is seen as an essential component in planning for the future
        health of the local population. Recently projects such as City Corridor, Soho HC and Hob Moor
        Road have benefited from Infection Control Input. ICNs see how consistently badly designed
        healthcare environments directly impact on patient’s health.




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4.      Education and Training

        The Infection Control Nurse Specialists are committed to providing a
        comprehensive educational programme for all grades of Health Care Workers
        within HoB PCT.

a)      The educational input has included:

         Two hour infection control updates on the NBPCT mandatory update days. These sessions
          includes basic microbiology, routes of spread of infection, universal precautions and
          handwashing theories as well as a workshop to consolidate learning.
         Educational sessions at clinical level on an at-request basis according to the educational needs of
          the staff. This has recently included sessions on influenza, MRSA, universal precautions and
          decontamination.
         Contribution to the Tissue Viability Study Days, Continence Study Days, Phlebotomy training
          days by providing sessions on Infection Control.
         Educational sessions are available and have been accessed by Estates staff
         Education sessions are available for all grades of community staff throughout the PCT including
          Care home staff, School Nurses, Students and Podiatrists.
         Educational sessions for student nurses including undergraduates, cadets, and district nurse
          students. This education is both practical and theoretical.
         Educational sessions have been provided for medical staff including paediatricians, and dentists.
         An educational session for Ambulance staff is hoped to be achieved during 2004.

        District Nurses are regularly sent information (research articles etc) which they are then asked to
        retain in their Infection Control Resource Folder for future reference and student use. The most
        recent information was the 21 page MRSA information pack along with directions on accessing the
        Control of Infection Policy and Procedure Manual on the intranet. Along with this information the
        most recent contact numbers were given.

b)      Infection Control Link Nurse Course

        The Infection Control Link Nurse Course (accredited at level 2 and 3 with the
        University of Central England (UCE) was run in April-June 2003.
        A District Nurse and School Nurse are included in the compliment of HoB PCT qualified link
        nurses. The aim of this course is to develop clinical practitioners who are able to
        create and maintain an environment that ensures the safety of the patient,
        the informal carers and healthcare worker in the prevention of infection.

        The course had been re-evaluated/re-accredited with the UCE during 2000 at
        both Level 2 and Level 3. Rearticulation is due May 2004. The link nurses fulfil their role in
        various ways this including: -

           The promotion of handwashing
           Monitoring and review of practices within their area
           Dissemination of information
           Early reporting of infection Control problems and outbreaks
           Promoting the need to adequately decontaminate equipment




HOBtPCT Control of Infection Annual Report            5
         Addressing food hygiene issues
         Audit of practices within individual areas.

        It is proposed that an additional 3 day Infection Control Link Nurse Course will be offered during
        October 2004.

c)      Infection Control Interest Group

        The Interest Group has now been running successfully since 1996. Meetings
        are held every 2 months. The meetings focus on an educational topic of interest (which often
        involves an invited specialist) followed by a business meeting where current issues are discussed.
        A review of these meetings was undertaken with a view to replacing them with
        a ½ day study session. However the attendees preferred to continue with
        meetings.

d)      Regional Infection Control Study Day

        The West Midlands Infection Control Nurses Association provides an annual Regional Study Day
        which was held on 29 October 2003 at Birmingham’s City Hospital. This day was attended by 70
        delegates. Staff from the four Birmingham Primary Care Trusts attended.


e)      Nursing Auxillary Study Day - November 2003

        This was the seventh successful study day provided specifically for Auxillary
        Nurses/Rehab/Healthcare Assistants. The day provides the staff with current
        information on infection control issues to support their practice. A total of
        69 staff attended, many from within the four Primary Care Trusts. This annual event will be offered
        biannually in 2004.

f)      Handwashing Roadshow

        The handwashing roadshow was undertaken by the Infection Control Nurse Specialists; Richard
        Lawn Rehabilitation Unit was visited and was well attended. The handwashing technique is
        demonstrated and clinical practices discussed. The ultra violet light handwashing machine is used to
        assist staff in identifying areas for improvement in their own technique. This teaching method is
        used during many of the training sessions provided.

5.      Infection Control Policy and Procedure Manual

        Currently there is one Infection Control Policy and Procedure Manual adapted by the four Primary
        Care Trusts. The Policies and Procedures contained within the Infection Control Manual continue
        to be reinforced during educational sessions. A policy review meeting now takes place every six
        weeks ensuring that the policies and procedures are kept up to date on a continuous rolling
        programme. A copy of the review dates for policies is included in Appendix 1. The Control of
        Infection Policy and Procedure Manual is available for staff to view on the Trust Intranet site.

6.      Audit and Monitoring of Practices

        A programme of Audit of Practices and the environment is undertaken within
        Each of the Birmingham Primary Care Trusts by the ICN’s on an annual basis (Appendix 3).




HOBtPCT Control of Infection Annual Report              6
        The West Midlands Infection Control Nurses Association tools are used.
        All audits reports are now issued with a traffic light score indicating the level of risk and urgency
        for remedial actions due, i.e. red = <75%, amber = 76-84%, green = >85% respectively.

        Richard Lawn has been audited and obtained a score of 68%, returning a red traffic light, this
        dictates immediate action, which has been acted on.

        The four vasectomy clinics hosted by Hobt PCT were audited and awards ranged from green to
        red. Estates and clinicians have been given advice on the way forward. These audit reports have
        resulted in one clinic being moved to improved premises still within easy reach for the local
        population.

        (Specialist areas including Child Development Centres, Special schools, etc have also recently been
        audited. Consequently these areas have received a customised programme of education presented
        in collaboration with Birmingham Health Protection Unit; however although these services have
        been delivered by the ICNs for the HoB PCT population they are hosted by other PCTs so shall
        not appear in detail here.)

        Other areas audited include Equipment Loan Stores. Following the risk assessment of the
        equipment store, the infection control team have been greatly involved in the planning of the new
        Devon Street decontamination unit.

7.      MRSA

        Laboratory based surveillance is carried out on MRSA isolates usually by City Hospital. Any
        positive isolates for in-patients are reported to the ICN and feedback is given to the unit and advice
        and treatment (If necessary) of patients advised.

8.      Outbreaks

        There have been two small outbreaks gastro-intestinal in origin at Richard Lawn Rehab Unit; The
        Environmental Services Department were also involved as they were visiting Social Services
        (downstairs) at the same time. Both outbreaks were very short-lived. Staff and premises were
        visited and given advice and support which enabled the situation to be dealt with effectively
        preventing further spread.

9.      Committees/Groups

        A committee has been established within HOBtPCT incorporating Control of Infection and
        Decontamination chaired by the Director of Public Health. This committee has the role of
        developing:

           a trustwide approach to control of infection and decontamination;
           receive reports regarding legionella, food hygiene, the management of outbreaks and audit
            reports;
           monitor progress against the Control of Infection and Decontamination Controls
            Assurance Standard.

        A copy of the Terms of Reference for the committee has been attached (Appendix 2).

        The Infection Control Nurses also attend the following groups/committees: -




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             North Birmingham Primary Care Trust Control of Infection Committee
             Eastern Birmingham Primary Care Trust Control of Infection Committee.
             Heart of Birmingham Primary Care Trust Control of Infection Committee.
             South Birmingham Primary Care Trust Control of Infection Committee (Elderly Directorate).
             South Birmingham Primary Care Trust Dental Hospital Infection Control Committee.
             University Hospital Birmingham NHS Trust Infection Control Committee.
             Joint Health Protection Liaison Meeting.
             Pan Birmingham Decontamination Sub-group.
             Policy Review Group.

10.       Controls Assurance

          The Trust was for compliance against the Control of Infection Standard in April 2003 and was
          assessed as having a compliance score of 69. There was some progress against action plan for
          overcoming those areas of non-compliance but it is anticipated that the revised service
          agreement will see the Control of Infection agenda taken forward even more effectively. Areas
          of progress include:

             new Board level responsibility for Control of Infection is clearly defined;
             The establishment of a suitably constituted Control of Infection Committee;

          The areas where work remains outstanding includes:

             the production of an annual control of infection report;
             a list of current policies and procedures;
             regular reporting to the Risk Management Committee;
             the development of key performance indicator indicators.

          A copy of the action plan is attached Appendix 4

Conclusion

The demands upon the Infection Control Nursing Service continue to increase and expand and develop in
line with the Governments recent drive to promote infection control, a cleaner environment and improved
clinical practices within healthcare facilities throughout the Trust.

The recent audits carried out within the Heart of Birmingham Primary Care Trust demonstrate continuing
adherence to Infection Control Policies and Procedures. Recommendations/issues highlighted from these
audits are addressed with the individual areas and also through educational programmes.

The Infection Control Link Nurses continue to be valuable and enthusiastic members, who promote
infection control within the clinical areas where they work.

The Infection Control Nurse Specialists have embraced the changes that have occurred with the formation
of the four Primary Care Trusts ensuring that Infection Control remains a high priority.

The intention for next year is to extend the current work being carried out and in addition undertake:

         An audit of a selection of Health Centres - to be determined by HC Managers;
         An extra Infection Control Link person course to include all disciplines;
         Decontamination workshops for Practice Staff;
         Increased time in induction sessions to include the Hand washing Theories and Workshop.




HOBtPCT Control of Infection Annual Report           8
Renewal Date for Policies in the Infection Control Manual                                                    Appendix       1

No.     Section                                                            Date Reviewed               Date to be Renewed
        Section One – Service Details
1.1     Infection Control personnel
1.2     Committee details and Membership                                   Jan 2004                    One year
        Section Two – Emergency Procedures
2.1     Outbreak Policy                                                    updated Feb 03              Feb 2005
2.1.1   Individual Team Members Responsibilities                           updated Feb 03              Feb 2005
2.2     Inoculation Policy                                                 updated Feb 03              Feb 2005
2.3     Legionnella Outbreak Plan                                          updated Mar 03              Feb 2004
        Section Three – Principles & Generic Infection Control Policies
3.1     Handwashing                                                        updated Mar 03              March 2005
3.2     Universal Precautions                                              updated Mar 03              March 2005
3.3     Protective Clothing                                                updated Mar 03              March 2005
3.4     Management of Spillages                                            updated Mar 03              March 2005
3.5     Sharps Handling and Disposal                                       updated Mar 03              One year
3.6     Specimen Collection                                                updated Mar 03              One year
3.7     Minor Surgery Requirements                                         updated Mar 03              One year
3.8     The A – Z of Decontamination                                       Jan 2004                    One year
3.8.1   Decontamination of Healthcare Equipment                            Jan 2004                    One year
3.8.2   Decontamination of Beds and Mattresses                             Dec 2003                    One year
3.8.3   Decontamination of Equipment prior to servicing & return to CSSD   Jan 2004                    One year
3.8.4   Procedure for the Decontamination of Equipment for Inspection,     Dec 2003                    One Year
        Service or Repair
3.8.5   Decontamination of Equipment/Instruments Primary Care              Jan 2004                    One year
3.9     Care of patients with Creutzfeldt – Jakob Disease                  Jan 2004
3.10    Ambulance Transfers                                                Oct 2003 – still            Oct 2005
                                                                           being updated
3.11    Last Offices                                                       Oct 2003 – still            Oct 2005
                                                                           being updated
3.12    Management of Patients with diarrhoea and vomiting                 updated Mar 03              March 2004
3.13    Guidance for the prevention of diarrhoea and vomiting outbreaks    updated Mar 03              March 2004
3.14    Hydrotherapy Pool Guidance and Sampling                            Jan 2004                    Every 2 years
3.15    Medical Devices – see separate policy                              Individually updated        Every 2 years
                                                                           by separate cttee
3.16    Influenza                                                          Dec 2003                    Every 2 years
        Section Four – Hospital Specific Policies
4.1     Patient Isolation                                                  March 2004                  Every 2 years
4.2     Decontamination of Nursing Equipment                               April 2004                  Every 2 years
4.3     Waste Disposal – see separate policy                               Individually updated        Every 2 years
                                                                           by separate cttee
4.4     Linen                                                              April 2004                  Every 2 years
4.5     MRSA                                                               March 2004                  Every 2 years
        Section Five – Infectious Diseases
5.1     Individual Diseases                                                Oct 2003 –          still   Oct 2005
                                                                           being updated
5.2     Notification of Infectious Diseases                                March 2003                  Every 2 years
        Section Six – Staff Health
6.1     HIV/Aids and Work – Guidance for Employees                         June 2004                   Every 2 years
6.2     HIV/Aids – Infected Health Care Workers: Practical Guidance on     June 2004                   Every 2 years
        Notifying Patients
6.3     Infection Risks to New and Expectant Mothers in the Workplace      July 2004                   Every 2 years
        Section Seven – Food Hygiene
        See separate policy                                                Individually updated        Every 2 years
                                                                           by separate cttee
        Section Eight – Infection Control in Schools
8.1     Infectious Diseases in Schools                                     Yet to be decided           Every 2 years
        Section Nine – Nursing and Residential Homes
9.1     Infection Control in Nursing Homes and Residential Homes           Yet to be decided           Every 2 years




HOBtPCT Control of Infection Annual Report                         9
                                                                                               Appendix 2


           CONTROL OF INFECTION AND DECONTAMINATION COMMITTEE
                       MEMBERSHIP AND TERMS OF REFERENCE

Introduction
The Trust has established a Control of Infection and Decontamination Committee to ensure that systems
and processes are in place to prevent and control the risk of infection to patients, staff and visitors.

Membership
The members will responsible for providing expert advice and for co-ordinating or undertaking work at the
request of the Committee.
The Committee will have the following membership


             Director of Public Health, Chair of Committee
             Assistant Director of Learning and Governance, Deputy Chair of Committee
             Consultant Microbiologist
             Control of Infection Consultant
             Control of Infection Nurse
             Deputy Director of Estates and Central Facilities
             Risk Manager
             Consultant in Communicable Disease
             Trust Health and Safety Advisor
             Consultant in Occupational Health Medicine
             Representative from each Clinical Directorate
             Clinic Practice Nurse
             General Practitioner Representative

Frequency of Meetings

The Control of Infection Committee will meet every two months.

Reporting Arrangements

The Committee will report to the Risk Management Committee on a biannual basis and present an annual
report to the Trust Board.




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Quorum
The committee will be considered quorum to make decisions when a minimum of half the committee
including the chairman or vice chairman, a Control of Infection Consultant, a Control of Infection Nurse
and the Risk Manager are present.

Terms of Reference

The Infection Control and Decontamination Committee will:

1. Develop a Trustwide approach to Control of Infection and Decontamination, ensuring that all
     environments and working practices are safe, effective and comply with national guidance.
2. Ensure that the lines of accountability for minimising the risk of infection are clear and explicit
     throughout the organisation.
3. Develop and review related policies and procedures and oversee their implementation.
4. Ensure that staff receive training in Control of Infection and Decontamination practices and that there
     are systems in place to record evidence of training.
5. Receive regular reports from the Infection Control team, and where appropriate regarding Food
     Hygiene, Legionella and the management of outbreaks of infection.
6. Monitor and co-ordinate responses and submissions to external organisations on behalf of the Trust.
7. Monitor progress against the Controls Assurance Control of Infection and Decontamination Standards
     and report as required.
8. Report to the Risk Management Committee on a biannual basis and present the Infection Control
     annual report and plan to the Trust Board.
9. Agree an annual Trust wide programme for the management of decontamination and report progress
     against the plan on a bi-annual basis.
10. Identify and maintain an annual programme of audit for control of infection practice.
11. Ensure that Control of Infection is considered when purchasing new equipment, altering buildings or
     building new clinical areas, that the existing are suitable and safe and that the environment is
     monitored. All significant alterations and findings should be reported to the committee.
12. Co-ordinate with the other Birmingham Primary Care Trusts to develop the current Service Level
     Agreement for the provision of Infection Control service to ensure it provides suitable and sufficient
     support.
Review
These Terms of Reference will be reviewed annually by the Control of Infection and Decontamination
Committee and approved by the Risk Management Committee




HOBtPCT Control of Infection Annual Report            11
                                             Heart of Birmingham PCT
                                           Control of Infection Programme
                                                        2003/4                                                 Appendix 3

                                   Schedule                         Result                              Action plan
Establish Induction       Monthly teaching session     Staff have regular IC input         To increase session time as hand washing
programme                                                                                  workshop not able to be included


                         Inpatient areas:              Audit result 68%                    Audit report sent to Unit Manager and
Initiate Audit programme Richard Lawn                                                      risk management
establishing priorities
                         High risk areas:
                         Vasectomy clinics             Treaford Lane 44%                   Audit report sent to Risk Manager and
                                                                                           Unit Manager

                                                       Sutton Cottage 49%                  Request to risk manager to be entered on
                                                                                           risk register

                                                       St Patricks 88%                     Audit report to be sent to DPH, Risk
                                                                                           Manager, Lead Clinician

                                                       Broadmeadow TBA



Advise     on     Capital City Corridor project        Infection      Control        Input Advice given by ICT and changes made
Planning                                               established.
                                                                                           Meeting arranged 23.1.04
                          Soho Health Centre Project   Meet with Architects prior to
                                                       plans being drawn up
                                                                                                                                                                         Appendix 4
                                CONTROL INFECTION/CONTROLS ASSURANCE ACTION PLAN 2003 – 04

Ref   Std             Risk description                          Action description              Imp       Like   Rsk   Start date   Review date   Cost    Responsibility           Proposed Actions Taken
                                                                                                 ct       lihd
                         Example risk                                                            1          1    L     1-Apr-2003   31-Mar-2004   £0
 1    IN    Board level responsibility for Infection    Definition of position of Infection      3         1     H     1-Apr-2003   31-Mar-2004   £0      Chief Executive      Director of Public Health Chair of
            Control is clearly defined and there are    Control team within Trust hierarchy                                                                                    Infection Control Committee and
                clear lines of accountability for                                                                                                                                  accountable to the Board
             infection control matters throughout
                             the PCT
 2    IN         There is an infection Control          To establish Terms of reference and      3         1     M     1-Apr-2003   31-Mar-2004   £0     Director of Public HOB infection Control Committee to
                 Committee which is directly             agreed lines of accountability that                                                                  Health        meet 06.01.04 to produced proposals
             accountable to the Chief Executive              include the Trust Board.                                                                                        for RMC to recommend to Trust
              and Trust Board that endorses all                                                                                                                                            Board
                infection control policies, and
            guidance, provides advice and support
            on the implementation of policies, and
             monitors the progress of the annual
                     control programme
 3    IN     There is an appropriately constituted       The Control of Infection Team is        4         2     H     1-Apr-2003   31-Mar-2004   £0     Director of Public    SLA to define role of C of I team
              and functional Infection Control             provided under an SLA from                                                                         Health          particularly in relation to programme
                            Team                         University Hospitals Birmingham,                                                                                     of work and routine management of
                                                       providing advice, training and dealing                                                                                             infection issues
                                                                  with outbreaks

 4    IN    Prevention and control of infection is     The Trust needs to develop protocols      3         3     H     1-Apr-2003   31-Mar-2004   £0     Director of Public    SLA to define role of C of I team
               considered as part of all service         for including the Col Team in the                                                                    Health          particularly in relation to programme
                    development activity                  planning of services and building                                                                                   of work and routine management of
                                                       requirements, in the new procurement                                                                                               infection issues
                                                       of all new equipment/devices and any
                                                        contract in which there is an element
                                                                of control of infection.

 5    IN    An organisation wide annual infection          There is a need to review the         4         1     M     1-Apr-2003   31-Mar-2004   £0     Director of Public   Infection Control Nurse to produce
               control programme with clearly            programme to ensure all areas in                                                                     Health          Annual Control of Infection Report
            defined objectives is produced by the       which the Trust has employed staff                                                                                         for February Trust Board
                  Infection Control Team                            are covered.

 6    IN      Written policies, procedures and          All policies will need to be approved    4         2     H     1-Apr-2003   31-Mar-2004   £0     Director of Public     Committee needs to list of current
              guidance for the prevention and          by an infection control team and trust                                                                 Health             policies and procedures that it is
            control of infection are implemented            policy review group or similar                                                                                     responsible for, and those that need
             and reflect relevant legislation and                                                                                                                              producing, and then programme for
              published professional guidance                                                                                                                                   their development implementation
                                                                                                                                                                              and review. To be undertaken by Risk
                                                                                                                                                                                      Manager & C of I Nurse




HOBtPCT Control of Infection Annual Report                                                           13
 7    IN   There is an annual programme for the         An annual programme of audits to         4        2   H   1-Apr-2003   31-Mar-2004   £0   Director of Public   Infection Control Nurse to produce
           audit of infection control policies and     ensure that it covers relevant aspects                                                          Health          Annual Control of Infection Report
                         procedures                        for the employed staff to be                                                                                     for February Trust Board
                                                                     introduced
 8    IN      Timely and effective specialist            The microbiology laboratory is          3        1   M   1-Apr-2003   31-Mar-2004   £0   Director of Public   Committee needs to list of current
            microbiological support is provided        accredited. Written procedures for                                                              Health           policies and procedures that it is
             for the infection control services         specimen collection, handling and                                                                             responsible for, and those that need
                                                                   disposal.                                                                                          producing, and then programme for
                                                                                                                                                                       their development implementation
                                                                                                                                                                     and review. To be undertaken by Risk
                                                                                                                                                                             Manager & C of I Nurse
 9    IN   Surveillance of infection is carried out        Methods of surveillance are           3        2   M   1-Apr-2003   31-Mar-2004   £0   Director of Public   Committee needs to list of current
           using defined methods in accordance        undertaken against agreed objectives.                                                            Health           policies and procedures that it is
            with agreed objectives and priorities,    The Control of Infection Committee                                                                              responsible for, and those that need
             which have been specified in the          are developing priorities that will be                                                                         producing, and then programme for
           annual infection control programme.        included in the forthcoming Annual                                                                               their development implementation
                                                          Infection Control Programme.                                                                               and review. To be undertaken by Risk
                                                                                                                                                                            Manager & C of I Nurse

 10   IN    A comprehensive infection control          The report includes progress on the       3        2   M   1-Apr-2003   31-Mar-2004   £0   Director of Public   Infection Control Nurse to produce
            report is produced by the Infection        infection control programme, review                                                             Health          Annual Control of Infection Report
           Control Team on an annual basis and        of adverse incidents, surveillance data,                                                                              for February Trust Board
                  presented to the Board                education and audits. The report is
                                                      approved by the Control of Infection
                                                      Committee and then to the Board via
                                                          Risk Management Committee.

 11   IN   The Infection Control Committee and Information from the Department of                2        1   L   1-Apr-2003   31-Mar-2004   £0   Director of Public     This information is accessible for
            Infection Control Team have access Health is available. Staff have access                                                                  Health            Infection Control Staff, can it be
           to up-to-date legislation and guidance to the COIN database, Health &                                                                                       highlighted for access by operational
               relevant to Infection Control       Safety Executive's and Controls                                                                                                 staff as well?
                                                  Assurance Support Unit websites.

 12   IN      Education in Infection Control is         A programme of ongoing education         4        2   H   1-Apr-2003   31-Mar-2004   £0   Director of Public     Committee needs to list of current
               provided to all healthcare staff,      for existing staff, includes updating of                                                         Health             policies and procedures that it is
            including those employed in support          policies, feedback of audit results,                                                                           responsible for, and those that need
                          services.                     highlighting and supporting actions                                                                             producing, and then programme for
                                                      arising from audits, roadshows, update                                                                             their development implementation
                                                            training for existing staff and                                                                            and review. To be undertaken by Risk
                                                       induction awareness sessions for new                                                                                  Manager and C of I Nurse
                                                      staff. All training is documented and
                                                         a review of where the Trust keeps
                                                       records of staff accessing any training
                                                                    to be planned.




HOBtPCT Control of Infection Annual Report                                                           14
 13   IN     Key indicators capable of showing      The Trust has developed draft key           4        2   H   1-Apr-2003   30-Jun-2004   £0   Director of Public   Draft key indicators to be presented
             improvements in infection control         indicators that are capable of                                                                 Health          to the committee and agreed, and a
           and/or provising early warning of risk demonstrating compliance with the                                                                                     programme of monitoring and
                are used at all levels of the     standards and which can demonstarte                                                                                          reporting agreed.
           organisation, including the Board, and    improvements in risks over time.
               usefulness of the indicators is    These will be agreed by the Control of
                     reviewed regularly.           Infection Committee and the Board
                                                    will select appropriate indicators to
                                                  monitor the Infection Control Service

 14   IN     The system in place for infection          The Infection Control Committee         3        3   H   1-Apr-2003   31-Mar-2004   £0   Director of Public Regular reporting to Risk management
           control is monitored and reviewed by         along with the Risk Management                                                                Health            Committee, with reports when
            management and the Board in order          Committee will monitor and review                                                                               required to Clincial Governance
           to make improvements to the system            the existing system to highlight                                                                            Committee, PEC and Trust Board
                                                      significant information to the Board.
                                                     The Infection Control Committee also
                                                       reports to the Clinical Governance
                                                      Committee. The Infection Control
                                                        Service as a whole is reviewed by
                                                     Internal Audit and a report produced.

 15   IN        The Board seeks independent          Management arrangements include an         3        2   M   1-Apr-2003   31-Mar-2004   £0   Director of Public Audit and review of service to be part
              assurance that an appropriate and      internal audit function, quality control                                                         Health               of annual C of I plan?
            effective control is in place and that              and clinical audit
             the necessary level of controls and
            monitoring are being implemented.




HOBtPCT Control of Infection Annual Report                                                          15

								
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