Infection Control and Decontamination Strategy

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					              Infection Prevention and Control and
                    Decontamination Strategy


Document information (does not change)
 Board Library   Document     Document Subject   Original Document      Assured by       Review
  Reference        type                                Author                             Cycle

                 Strategy        Infection         Director of         Integrated        1 year
                              Prevention and        Infection         Governance
CLI_IGCS_02
                               Control and       Prevention and       Committee
                             Decontamination         Control




    Version Tracking (updated for all subsequent versions)
     Version     Date           Revision Description                 Editor      Status
        1.1      Dec 08     Safety Forum                       DJ                    Draft
        1.2      Jan 08     Integrated Governance              DJ                    Draft
        1.3      Jan 08     Approved by Board                  DJ               Approved
        2.0      Jan 09     Updated and approved by            DJ               Approved
                            Board
CLI_IGCS_02                                    Infection Prevention and Control and Decontamination Strategy.                            _


                                                            CONTENTS


1.          Introduction......................................................................................................... 3

2.          Principles ............................................................................................................ 5

3.          Delivery Of Services ........................................................................................... 5

4.          Infection Control Assurance Framework.......................................................... 6

5.          Structure And Communication.......................................................................... 7

6.          Assurance Mechanisms – Monitoring compliance........................................ 12

7.          All Hazard Risk Assessment ........................................................................... 15

8.          Workplan ........................................................................................................... 19

9.          Monitoring and Reporting ................................................................................ 22

10.         Education and Training .................................................................................... 22

11.         Decontamination .............................................................................................. 23

12.         Performance Monitoring .................................................................................. 24

13.         Summary ........................................................................................................... 25




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1. Introduction

    1.1 Infection prevention and control within a Mental Health Trust provides different
        challenges to the challenges within other healthcare settings.         Different
        challenges are not to be confused with less important challenges. The
        prevention of infections within a Mental Health Trust are as those in the acute
        sector.

    1.2 In recent years, Healthcare Associated Infection (HCAI) has been identified as a
        major national priority, and as such was identified within the Chief Medical
        Officer‟s (CMO) Infectious Diseases Strategy for England, Getting Ahead of the
        Curve (DOH 2002).

    1.3 More recently, in December 2003, the Department of Health (DOH) published
        “Winning Ways” (DOH 2003). This report provided a summary of the issues
        associated with reducing HCAI, and advises that despite clearly communicated
        advice from the DOH over the last five years, HCAI have not been given as high
        a priority for action as some other aspects of healthcare.

    1.4 These findings were more recently substantiated within the National Audit Office
        Report (NAO 2004), which concluded that progress in preventing and reducing
        HCAIs was limited and constrained by lack of data nationally on the extent and
        cost of HCAI, an increase in the numbers of outbreaks such as Norovirus,
        conflicting priorities within the healthcare sector, the emergence of strains of
        multi-resistant bacteria, and the need to change staff behaviour and attitudes
        toward reducing HCAI.

    1.5 Recommendations within the NAO report (NAO 2004) and Winning Ways (DOH
        2003) clearly advise a new approach toward reducing HCAIs, through:



               Ensuring uncompromising commitment from Board to Ward and managerial
                and clinical leaders nationally and locally
               Making HCAI a visible and unambiguous indicator of the quality and safety of
                patient care
               Applying rigorously and consistently the measures known to be effective in
                reducing the risks of HCAI
               Enabling the provision of high quality information for the public and service
                users as well as clinical teams so that the risks associated with the
                performance of certain procedures are transparent.




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    1.6 In October 2006 (revised Jan 2008), The Health Act Code of Practice for the
        Prevention and Control of Healthcare Associated Infections identified eleven key
        action areas for NHS Trusts to implement in order to develop and inform local
        strategy and policy. These are listed below, and provide the focus for AWP
        infection prevention and control strategy:

            1.       General duty to protect patients, staff and others from HCAIs
            2.       Duty to have in place appropriate management systems for infection
                     prevention and control
            3.       Duty to assess risks or acquiring HCAIs and to take action to reduce or
                     control such risks
            4.       Duty to provide and maintain a clean and appropriate environment for
                     healthcare
            5.       Duty to provide information on HCAIs to patients and the public
            6.       Duty to provide information when a patient moves from the care of one
                     healthcare body to another
            7.       Duty to ensure co-operation
            8.       Duty to provide adequate isolation facilities
            9.       Duty to ensure adequate laboratory support
            10.      Duty to adhere to policies and protocols applicable to infection prevention
                     and control
            11.      Duty to ensure, so far as is reasonably practicable, that healthcare
                     workers are free of and are protected from exposure to communicable
                     infections during the course of their work, and that all staff are suitably
                     educated in the prevention and control of HCAIs

    1.7 The Infection Prevention and Control Strategy for AWP provides an
        organisational approach toward reducing HCAI and achieving compliance with
        the Health Act code and National targets. In particular, this document defines the
        key standards through which the efficacy of the strategy can be monitored,
        reviewed regularly, and improved upon.


    1.8 CNST standard for infection control is integral to this strategy.
         the infection control assurance framework,
         details of or cross reference to all core clinical protocols
         making information available to service users and the public about the
          general processes and arrangements for preventing and controlling
          healthcare acquired infections.

    1.9 The success of the strategy will be reliant upon support, ownership, and
        accountability across all levels of the organisation from the Trust Board to front
        line operational staff in all services.



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2. Principles

    2.1 This strategy aims to ensure service users of the Trust receive high quality care
        through service provision, which is safe and effective, and that staff work in safety
        focussed environments.

    2.2 The culture within which the Trust will manage the risk of infection will be centred
        around service users with an emphasis on continuous quality improvement. This
        will include working in partnership with service users, carers, staff and other
        organisations involved with services in an open and transparent manner.

    2.3 The Trust recognises that every healthcare worker has a vital role to play in
        helping to minimise the risk of cross infection and that standard precautions
        underpin safe working practice protecting staff, service users and the public from
        infection.

    2.4 The Trust endorses the following standard precautions:

               achieving optimum hand hygiene for everyone
               using personal protective equipment
               safe handling and disposal of sharps
               safe handling and disposal of clinical waste
               managing blood and bodily fluids
               decontamination of equipment
               achieving and maintaining a clean clinical environment
               managing incidents appropriately
               good communication between staff, service users, carers and visitors
               training and education
               monitoring and surveillance
               safe transfer of patients between healthcare and other settings

3. Delivery Of Services

    3.1 The Trust‟s infection prevention and control service consists of a Director of
        Infection Prevention and Control, an Infection Control Nurse, and a Personal
        Assistant.   This team co-ordinates the Trust‟s arrangements for infection
        prevention and control and provide strategic leadership.

    3.2 The Trust‟s Infection Prevention and Control Team is supported by Service Level
        Agreements with local District General Hospital Infection Control Teams. They
        provide advice over a 24 hour period to in-patient sites. The Health Protection
        Agency provide out of hours advice for community services on an informal basis.

    3.3 Inpatient services adopt into use the policies of their local District General
        Hospital and would seek infection prevention and control advice from the District

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            General Hospital Infection Control Team. Telephone advice is available on a 24-
            hour basis. The District General Hospital Infection Control Teams provide
            information on alert organisms direct to the wards, and where necessary, inform
            the AWP Infection Control Team. Half-yearly meetings between the provider and
            Director of Infection Prevention and Control are arranged where issues and
            concerns are aired and resolved. Concerns arising between these meetings are
            made by direct contact at the time.

    3.4 Community services have adopted the policies of the Health Protection Agency
        and would seek urgent out of hours advice from HPA staff. Out of hours
        community cover is provided on an informal basis by the Health Protection
        Agency. AWP IC Team provides Day to day advice.

    3.5 The Trust gains access to professional and accredited decontamination facilities
        through a range of Service Level Agreements with District General Hospital CSSD
        Depts. The Trust‟s needs for such services are low, and wherever possible, the
        Trust has adopted the use of single-use items.

    3.6 Occupational health services promote staff and service user and environmental
        safety with regard to biological risks through the application and monitoring of
        robust health screening, risk management, immunisation programmes, and safe
        handling and disposal of sharps. The Trust accesses Occupational Health
        services through contract with a single independent provider, ATOS.

4. Infection Control Assurance Framework

The Infection Prevention & Control and Decontamination Strategy is integral to the
achievement of the Trust‟s objectives. The assurance framework for infection
prevention and control is to ensure effective systems are in place to prevent and control
healthcare associated infections and communicable diseases and adopt a robust
Trustwide approach whereby infection prevention and control practice is continuously
reviewed and improvement demonstrated through audit and surveillance activity. The
key objectives that form the assurance framework are:

    To have well established systems for assessing risk of infection, reporting infections,
     investigating infection related incidents and managing and reducing infection control
     risk across the Trust.
    To develop a robust contractual infrastructure for infection control and
     decontamination services with partner Trust providers and ensure close
     performance monitoring of service
    To ensure a full range of infection control policies and local procedures are in place
     and accessible to all staff.
    To ensure access for staff to infection control, microbiological and pharmaceutical
     expertise.
    To have a continually updated and monitored quality improvement action plan for
     Infection Control.
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    To collate, analyse, and share information relating to infection prevention and control
     with all stakeholders both from an organisational learning perspective but also to
     ensure all relevant information is passed on during patient transfers
    To collate and prioritise infection control risks and maintain an infection control risk
     register, escalating significant risks to the Trust Board.
    To support the development and training of staff in developing their skills for
     preventing and controlling infection control incidents.
    Engender a positive infection control culture that promotes the importance of hand
     hygiene to staff, service users, carers, visitors and to support the wider public health
     agenda.
    To be supportive of the wider environmental agenda including hospital cleanliness
     and waste management.
    To have in place a comprehensive infection prevention and control audit
     programme.
    To ensure compliance with government guidelines in respect of infection prevention
     and control and meet targets as deemed by DOH, SWNHS and HPA.
    To achieve external accreditation.

5. Structure And Communication

Pivotal to the success of this strategy is an acceptance of responsibility and
accountability for the prevention and control of healthcare associated infection
throughout the organisation. The Trust, Directorate teams, and the Infection Prevention
and Control Team all have a legal, moral, and organisational responsibility to service
users, staff, and stakeholders to ensure that all infection prevention and control risks are
identified, quantified, and effectively managed.

Specific responsibilities identified in support of this strategy are:

The Chief Executive has ultimate accountability for the prevention and control of
healthcare associated infections and ensures that the Trust fulfils its legal duties to
identify, assess, report and control risks of infection in the workplace, and enables the
Director of Infection Prevention and Control to have direct access to the Trust Board.

The Trust Board has collective responsibilities for minimising the risks of infection and
the general means by which it controls such risks.

The Director of Integrated Governance and Nursing has ultimate responsibility for
the prevention and control of HCAI, and as such, designates prevention and control of
healthcare associated infections as a core part of the Trust‟s integrated governance
arrangements. This Director ensures there are clear lines of accountability between
Risk Management, Clinical Governance, Infection Control and Senior Management and
ensures that quarterly reports on infection prevention and control are presented to the
Trust Board.


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The Medical Director is responsible for providing leadership to medical staff in respect
of infection prevention and control and for advising on contingency arrangements in
respect of outbreaks and advising on antibiotic prescribing. In this latter role, this
Director is supported by the Chief Pharmacist.

The Director of Operational Services is responsible for ensuring that a
comprehensive range of service level agreements are in place and that there are
appropriate contingency arrangements for isolation facilities.

The Director of Corporate Services is responsible for ensuring a safe environment for
service users, staff, and visitors by observing statutory and mandatory requirements
and national directives comprising environmental cleanliness, catering facilities,
ventilation systems, water supplies, and the safe handling of linen and waste. This
Director will ensure that the Trust‟s environments are visibly clean, free from dust and
soilage, and acceptable to service users, carers, visitors, and staff. Nominating a
representative to attend the IC Group and update the Group on cleaning and other
infection control related activities.

The Director of Finance and Performance is responsible that appropriate financial
contingency is made to manage infection control outbreaks or pandemics and that there
is an effective performance framework to monitor infection prevention and control
improvements.

The Director for People is responsible for ensuring that infection prevention and
control responsibilities are appropriate reflected in job descriptions and in KSF
competencies. This Director is also responsible for ensuring that a training needs
analysis exists for infection prevention and control training and for ensuring the delivery
of a range of relevant learning and development opportunities. In this latter role, this
Director is assisted by the Associate Director of Learning and Development who will
ensure that training uptake statistics are recorded and provided. The Director of HR is
responsible for ensuring that there are robust and effective arrangements in place in
relation to the provision of Occupational Health Services across the Trust and the
Occupational Health Service provides:
 Advice on all aspects of employee health and infection prevention and control
 Ensure a programme of health screening and vaccination for communicable disease
    is in place in accordance with national requirements
 Manage policies, procedures and processes for management of staff who have
    received a contamination injury.
 Ensure a programme of health screening is in place for those staff working in high
    risk areas for e.g. Varicella Zoster Screening for Mother & Baby Unit.

The Director of Infection Prevention and Control (DIPC) reports directly to the Chief
Executive and is line-managed by the Deputy Director of Nursing. This Director
provides the strategic leadership for infection prevention and control and
decontamination and co-ordinates all related activity. This Director will also take a
direct role in care, when indicated, challenging inappropriate clinical hygiene practice,
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as well as antibiotics prescribing decisions. This Director supports management and
clinical teams in the delivery of this strategy and works collaboratively with partner
Trusts, the Strategic Health Authority, and the Health Protection Agency. The DIPC
provides the annual Infection Prevention & Control report. The Decontamination lead
role is integral within the DIPC role.

The Infection Prevention and Control Team develops, leads the implementation of,
and monitors the infection prevention and control programme through the following key
functions:

   Provides advice and support for important development of surveillance and
    investigation including outbreak management and containment.
   Education and development of all health care professionals and personal professional
    development in conjunction with learning and development
   Policy and practice development in line with legislative requirements, national
    directives, and best practice.
   Monitoring hygiene and clinical practices and patient infection outcomes using audit
    processes and surveillance data. Provide results and reports to clinical teams and
    advising upon practice improvements.
   Research and development determining effectiveness of infection prevention and
    control interventions and activities and facilitating changes to improve clinical practice
    and service user outcomes.
   Advice and guidance on service developments with an emphasis on new build
    projects.
   Review statistics and education.

Clinical Directors are responsible for ensuring the delivery of safe and effective
infection prevention and control practices within their Strategic Business Units. These
Directors will ensure that there are link nurses identified and supported to provide local
leadership and training of infection prevention and control. Clinical Directors are
required to produce quarterly SBU infection control reports and to ensure that infection
control is a standing agenda item at their local governance forums. These Directors will
receive and act upon surveillance reports and ensure best practice is implemented.
They will participate in audit activity of infection prevention and control practices and
utilise audit results to inform and improve practice.

Infection Control SBU Directorate Lead
Directorate/Speciality Infection Control Leads will be responsible for ensuring that:
 All directorate related issues for infection control are discussed with the Clinical
    Director and there are channels for dissemination to all clinical staff within the
    directorate (e.g. results of audit, rates data, targets, etc.)
 Infection control is a standing item on the Directorate Clinical Governance Meeting
    agendas or equivalent
 Health Care Associated Infection (HCAI) data and audit information is received from
    Infection Control

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    To ensure that staff in the directorate are aware of progress against targets and of
     the current Clostridium Difficile rates and weekly surveillance information
    Action plans are developed and monitored in conjunction with the infection control
     team to identify how these infections will be reduced in each specific directorate
    Compliance with infection control policies and procedures is monitored
    As part of the action plan, areas are identified where the Essential Steps tool can be
     used as a means of reviewing, improving and changing practice where required
    They attend quarterly Infection Control Group meetings to report on progress in
     meeting targets and discuss any issues identified. A deputy must be identified to
     attend in the absence of the lead
    Hand Hygiene compliance audits are undertaken according to current standards
    Infection Control Link Practitioners identified within all clinical areas are attending
     meetings and undertaking their responsibilities as required and are provided with the
     necessary time to achieve this

Senior Managers, Heads of Nursing and Modern Matrons
 Must actively ensure all staff implement infection control policy and guidelines
 Must ensure adequate resources are available to meet infection control standards /
  requirements
 Must actively manage their staff to ensure they receive appropriate infection control
  training including training at induction and annual refreshers. Infection control
  training must be monitored via the appraisal process and be incorporated into
  personal training objectives.
 Modern Matrons prepare a quarterly IC report of IC actions for their area of
  responsibility that are presented by Clinical Directors at the IC Group, Integrated
  Governance and to the Board.
 Must ensure Infection Control Link staff have appropriate support, education and
  dedicated time to ensure they can carry out their role effectively
 Must ensure staff report infection outbreaks / incidents in accordance with the
  relevant infection control guidelines / policies
 Are responsible for ensuring that the Root Cause Analysis of service users acquire
  C Diff within their directorates are completed. The process begins with AWP
  Infection Control Team after notification from the Microbiologist. Final report with
  actions identified should be fed back to the Infection Control Group
 Are responsible for leading and driving a culture of cleanliness in clinical areas
 Are responsible for setting and monitoring standards of cleanliness in conjunction
  with others
 Must ensure equipment decontamination is performed in line with local, national and
  manufacturers‟ guidance.        This includes the provision of adequate training,
  equipment and environmental standards for staff to safely decontaminate equipment
 Must review the service user journey for emergency and planned service user in
  order to reduce the risk of transmission of infection by minimising the movement of
  potentially infected service users
 Must actively manage staff that do not adhere to infection control policy and
  guidelines to ensure compliance with Trust infection control standards
 Ensure arrangements are in place to support the annual infection control programme

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    Ensure that antimicrobial policies are implemented and up to date
    Ensure weekly surveillance monitoring is completed and forwarded to IC Team in a
     timely manor

Infection Control Link Practitioners will be responsible for raising the profile of
infection prevention and control activities within their team and for participating in and
delivering related training. They will have clear responsibilities for leading on local audit
programmes and the monitoring of local team based action plans. A role profile exists
for link practitioners and they will be responsible for complying with the requirements of
this role.

The Medical Device Liaison Officer is responsible for medical equipment within the
Trust and will seek the advice of the infection control team to ensure that new
acquisitions of equipment are considered in light of their ease to clean and
decontaminate. The Medical Device Liaison Officer is a member of the IC Group.

All Managers have a duty to ensure, so far as reasonably practicable, that health care
workers are free of and are protected from exposure to communicable infections during
the course of their work, and that all staff are aware of infection prevention and control
policies and procedures and are suitably educated in safe practice. They are
responsible for ensuring that infections are recognised, reported, and appropriately
communicated as well as ensuring all adverse infection control related incidents are
reported, responded to, and investigated in accordance with Trust policy. To ensure
that an appropriately skilled ICLP is designated within each clinical area and has
authority empowerment and resources to act effectively in the role.

All staff have a responsibility to abide by Trust policies, procedures and guidance, work
within professional codes of conduct, and participate in mandatory training programmes
and other training events. They must challenge and report any non-compliance with the
policies and report any infection control incidents or near misses. Above all, they must
work safely with within legislative requirements.

All Health Care Workers (all personnel who have contact with service user / clinical
specimens)
 Must ensure they have received appropriate infection control training, including hand
    hygiene instruction, in the last twelve months
 Must ensure they fully adhere to the Trust Hand Hygiene Policy
 Must never knowingly place a service user, member of staff or Trust visit at risk from
    an infection
 Must fully comply with the infection control standards set out in the Trust‟s infection
    control guidelines and policies
 Must adopt national evidence based guidelines in order to ensure service users are
    treated according to best practice
 Challenge poor infection control practice and seek support from the Line
    Manager/Supervisor/Infection Control Team as required

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    Communicate proactively and reactively with the Infection Control Team ensuring
     clear lines of communication
    Obtain advice from Occupational Health if they are concerned about risks to
     themselves

All Trust Employees (that do not have clinical contact with service users or samples,
etc.)
 Comply with infection prevention and control related policies, procedures, guidance
    and protocols
 Report concerns related to infection control as appropriate
 Report immediately to Occupational Health / Infection Control as appropriate if
    diagnosed or in contact with a communicable disease
 Adhere to advice given by Infection Control Team / Occupational Health Department

Information and Signage – Service Users/Visitors/Public
Information for service users, visitors and public on the Trust‟s infection control
arrangements is available, including:
 Trust intranet – Infection control section (leaflets can be downloaded from this site)
 Posters in public places asking visitors/public not to visit if had symptoms of
    diarrhoea & vomiting in the last 48 hours and challenge staff if not washed hands
 Leaflets providing information on Health Care Associated Infections                 and
    communicable diseases including; MRSA, Clostridium Difficile and Norovirus
    &Vomiting are available the Trust intranet

Information and Signage – Staff
Information for staff on infection control and their responsibilities is available from:
 Infection Control intranet Page
 Flyers sent out with pay slips (as required)
 From Infection Control Link Practitioners

Signage
 Hand washing signage for visitors is displayed at ward/department entrances
 If wards are closed due to infection control – signs are displayed at entrances with
   an explanation

6. Assurance Mechanisms – Monitoring compliance

The Trust Board will receive quarterly reports on infection prevention and control and
will receive an annual assurance report. The Trust Board will agenda time, as
requested, to hear directly from the Director of Infection Prevention and Control.

The Integrated Governance Committee is a reporting committee to the Trust Board
and will assure infection prevention and control reports and policies prior to submission
to the Trust Board.


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The Safety Forum reports to the Integrated Governance Committee and oversees the
work of the Infection Control Group, ensuring it receives an annual work plan and
reports on progress.

The Infection Control Group will bring together corporate staff with local services to
drive forward the infection prevention and control and decontamination agendas.

Core Clinical Policies
The Trust has in place core clinical policies in line with the requirements of the Code of
Practice for the prevention and control of healthcare associated infections (The Health
Act 2006 revised January 2008). Other Infection Control Policies are in place as
appropriate. These policies can be located on the AWP intranet. Hard copies can also
be found in the clinical areas.
 Standard (universal) infection control precautions
 Aseptic technique
 Major outbreaks of communicable infection
 Isolation of patients
 Safe handling and disposal of sharps
 Prevention of occupational exposure to blood-borne viruses (BBVs), including
   prevention of sharps injuries
 Management of occupational exposure to BBVs and post-exposure prophylaxis
 Closure of wards, departments and premises to new admissions
 Disinfection policy
 Hand Hygiene
 Antimicrobial prescribing
 Surveillance and reporting HCAIs to the Health Protection Agency (HPA) as directed
   by the Department of Health. This includes a mandatory requirement for the Trust‟s
   Chief Executive to report all cases of MRSA Bacteraemia and cases of C Diff
   infection in service users aged 2 years or older.
 Control of infections with specific alert organisms, taking account of local
   epidemiology and risk assessment. These infections must include as a minimum
   MRSA, C Diff infection and transmissible spongiform encephalopathy

Monitoring and Audit of Policies
The Trust Integrated Governance Committee is mandated by the Board to ensure the
successful adoption and implementation of this policy. Board Directors, SBU Directors,
Service and Clinical Directors and Line Managers are responsible for:
 Ensuring that all staff know how to access Trust-wide policy from the Board library,
   that material changes to Trust-wide policy and new policies are brought to the
   attention of all affected staff.
 Ensuring that Trust policies, procedures and protocols are implemented across their
   operational areas of responsibility. Individual staff members have a personal duty to
   work within the provisions of approved Trust-wide policies and their associated
   procedures and protocols. Failure to observe and implement policy and their related
   procedures and protocols is addressed through performance management
   mechanisms, training or where appropriate, the Trusts‟ disciplinary procedures.
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    Ensuring that all staff have access to up-to-date copies of all policies either via the
     Trusts intranet or in hard copy provided within the team base

Policies are updated in line with the policy for development, approval and management
of Trust procedural documents. The policy review date is included on the policy front
sheet.

The IC Group monitors compliance with the policy review date and changes in
legislation, best practice, etc. between the policy review dates. This triggers an early
policy update.
All AWP infection prevention and control policies are based on The Health Act Code of
Practice for the Prevention of Health Care Associated Infections, Dept. of Health
(October 2006). In exceptional circumstances, where a complex situation arises that
would not directly match this legislation, a risk management plan must be in place,
taking into account the diversity and best interests of staff, service users and the public.

All Trust infection protection and control policies will have completed an Equalities
Impact Assessment during their development. If a policy is required in a different
format, contact can be made with the Patient Advice and Liaison Service (PALS) based
at Trust Head Quarters, where this will be addressed.




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7. All Hazard Risk Assessment

The Trust‟s methodology for assessing risk is described in its Risk Management
Strategy and the following is its approved risk ranking matrix.

                                                RISK RANKING MATRIX

                            SEVERITY      NONE         MINOR      MODERATE        MAJOR             CATASTROPHIC
                                            1            2           3              4                    5


                               ALMOST       5            10            15            20                  25
 LIKELIHOOD OF RECURRENCE




                               CERTAIN    Yellow        Yellow       Orange         Red                 Red
                                  5

                                LIKELY      4              8           12            16                  20
                                   4      Yellow        Yellow       Orange          Red                Red



                               POSSIBLE     3              6            9            12                  15
                                  3       Green         Yellow       Orange          Red                Red



                               UNLIKELY     2              4            6            8                   10
                                   2      Green          Green        Yellow       Orange               Red



                                 RARE       1              2            3            4                   5
                                   1      Green          Green        Yellow       Orange               Red




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    SCORE                       DESCRIPTOR                                  DETAILED DESCRIPTION
            1           Rare                                May occur only in exceptional circumstances
            2           Unlikely                            Don‟t expect it to happen again but it is possible
            3           Possible                            May recur occasionally
            4           Likely                              Will probably occur in most circumstances
            5           Almost certain                      Will undoubtedly recur, possibly frequently

OUTCOME/SEVERITY

   1        None                         No obvious harm, loss or damage
   2        Minor                        Non-permanent harm, loss or damage
   3        Moderate                     Semi permanent harm, loss or damage
   4        Major                        Major permanent harm loss or damage
   5        Catastrophic                 Devastating Injury/unexpected or unexplained death




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Each of the hazards identified have been assessed as follows:

INFECTION                                                              LIKELIHOOD IMPACT SCORE
Acinetobacter spp                                                           3        1     3
Acquired Immunodeficiency Syndrome (AIDS)                                    1              5          5
Anthrax (Bacillus anthracis)                                                 1              5          5
Avian influenza (Bird Flu)                                                   2              5         10
Blood borne viruses and occupational exposure                                3              3          9
Campylobacter                                                                3              3          9
Chickenpox (VZV)                                                             3              4         12
Chlamydia                                                                    3              2          6
Cholera                                                                      1              5          5
CJD (Creutzfeldt-Jakob Disease)                                              1              5          5
Clostridium difficile                                                        3              5         15
Diphtheria                                                                   1              3          3
Dysentery                                                                    1              5          5
E. coli enteritis                                                            2              5         10
Encephalitis                                                                 1              5          5
Food poisoning                                                               3              4         12
Fungal infections                                                            3              2          6
German measles                                                               3              3          9
Gonorrhoea                                                                   2              2          4
Group A streptococci                                                         3              3          9
Group B streptococci                                                         3              3          9
Group C/G streptococci                                                       3              3          3
HBV (Hepatitis B virus)                                                      4              4         16
HCAI HCV (Hepatitis C virus)                                                 3              4         12
Headlice                                                                     3              1          3
Helicobacter pylori                                                          3              1          3
Hepatitis A                                                                  5              3         15
Hepatitis E                                                                  3              4         12
HIV                                                                          3              5         15

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Influenza                                                                    4              3         12
Legionella                                                                   2              5         10
Legionnaires' disease                                                        2              5         10
Listeria                                                                     3              4         12
Lyme disease                                                                 3              3          9
Malaria                                                                      1              3          3
Measles                                                                      3              3          9
Meningococcal disease                                                        2              4          8
Methicillin resistant Staphylococcus aureus                                  3              5         15
(MRSA)
Mumps                                                                        3              3          9
Norovirus                                                                    3              4         12
Norwalk-like virus                                                           3              4         12
Pandemic Influenza                                                           3              4         12
Pneumococcal disease                                                         2              4          8
Polio                                                                        1              3          3
Salmonella                                                                   2              5         10
SARS (Severe Acute Respiratory Syndrome)                                     1              5          5
Sexually Transmitted Infections (STI)                                        3              3          9
Smallpox                                                                     1              5          5
Staphylococcus aureus                                                        3              3          9
Streptococcal infections                                                     3              3          9
TB (Tuberculosis)                                                            3              3          9
Tetanus                                                                      2              3          6
Ticks                                                                        2              1          2
Typhoid                                                                      1              5          5
Urinary Tract Infection (UTI)                                                3              3          9
Whooping cough                                                               1              5          5




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The profile of the Trust‟s infection control all hazard risk assessment is therefore:


                                           RISK RANKING MATRIX

                 SEVERITY           NONE          MINOR      MODERATE        MAJOR            CATASTROPHIC


                    ALMOST                                        4             0                  0
                    CERTAIN
 LIKELIHOOD OF
  RECURRENCE




                                      10             5

                     LIKELY            0              2           11            1                  0

                    POSSIBLE           3              0           12            1                  1

                    UNLIKELY           0              1           2             0                  0

                      RARE             0              1           2             0                  0

The top risks faced by the Trust from an infection control perspective are:

Clostridium difficile – greatest impact in older adult services
Hepatitis B – greatest impact in SDAS and adult services
HIV – greatest impact in SDAS and adult services
MRSA – greatest impact in in-patient areas

The contingency arrangements for the top risks are contained in the policies for the
management of outbreaks, safe management of Sharps and Occupational Health
policies.

Additionally, an Infection Control Risk Register is maintained and subject to regular
review.

8. Workplan

The Trust will develop and seek Trust Board approval to an annual infection prevention
and control work programme. The annual work programmes will be robust documents
addressing the Trust objectives and will be dynamic documents, amended in the light of
new and/or shifting priorities within the infection prevention and control arena and/or
Trust agenda.




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The work plan will contain objectives at corporate and directorate/team level as well as
for the Infection Prevention and Control team. The work plan‟s objectives for 2007 –
2009 are:




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                                  Objective                                 Trust      Directorates IP&C
                                                                            wide
1 To develop an IP&C strategy based on the Act.                                                        
   The strategy is used as a working document by all
   teams in the Trust
2 To devise, implement and monitor an action plan                                                      
   to reduce significant HCAIs including MRSA
   Bacteraemias and Clostridium Difficile.
3 To implement and be fully compliant with the DOH                                                     
   Health Act code of practice 2006.
4 To devise and implement an IP&C educational                                                          
   programme for all healthcare professionals
   informed by audit and surveillance reports in order
   to develop/improve clinical practice
5 To promote and embrace IP&C objectives within                                                       
   each directorate governance plans and activity.
6 To undertake recommended surveillance and                                                            
   ensure surveillance reports are acted upon to
   inform and improve clinical practice
7 To contribute toward the implementation of the                                                       
   Matrons Charter and demonstrate an improved,
   safer environment through the audit process.
8 To demonstrate improvement in hand                                                                    
   decontamination practices through the audit
   process.
9 To be fully participative on the NPSA clean your                                                     
   hands Campaign.                                                                      (with ICLNs)
10 To review and strengthen the IP&C Link                                                               
   Practitioner network
11 To observe IP&C evidence based practice and                                                         
   legislative requirements within all local clinical
   guidelines and policies.
12 To continue to undertake organisational and local                                                   
   audit/assessment and implement action plans to
   achieve 95% compliance.
13 To monitor, improve and demonstrate prudent                                                          
   antibiotic prescribing.
14 To ensure substantial involvement and                                                               
   collaborative working within the wider health care
   community including the SHA and HPA.
15 To devise and implement an audit programme of                                                        
   key IP&C policies and functions.
16 Review and monitor current IP&C provision                                                            

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9. Monitoring and Reporting

Formal monitoring of and reporting upon the progress of the infection prevention and
control programme will be within the integrated governance framework and reporting
directly to the Board.

Systems currently in place are shown below:

    Weekly Surveillance of Outbreaks & Alerts by the IC Team reported quarterly to
     the IC Group and also Integrated Governance and quarterly Board Reports.
    SBU local Infection Control Leads and Clinical Directors feed into the Infection
     Prevention and Control group information on such activities in their areas of
     responsibility
    Quarterly Modern Matron reports are presented through the Infection Control
     Group and Safety Forum to the Board
    Infection Prevention & Control Group monitors the infection prevention and
     control programme and responds to new guidance or issues. This group has both
     corporate and operational representation. This group prepares quarterly reports to
     the Safety Forum.
    Trust Board - noting and commenting on infection prevention and control work
     programme, performance and risks.
    Key risks/issues, which arise and need to be addressed outside of the formal
     reporting and monitoring system, will be raised immediately by the DIPC with the
     Director of Integrated Governance and/or Nursing/Chief Executive depending upon
     the level of risk and degree of urgency.
    An annual audit programme is in place. The infection prevention and control work
     programme will contain a schedule of audits that will be undertaken each year.
     Reported through Audit Group, IC Group and Local Governance Groups.

10. Education and Training

Education and training is provided in a variety of ways. The Director of Infection
Prevention and Control advises on training. The Infection Control Team provide training
packages, and evaluates training in line with the IC training matrix (see Appendix).
All clinical staff are required to attend IC updates that would include reinforcing IC
responsibilities as indicated in the matrix.

Infection control training is available to all staff through the e-learning process.
Induction, MOT and Infection Control Link Practitioner training is delivered via the
training and development team and the Infection Control team staff. Records are held
centrally by the training department. All Modern Matrons, ICLP and medical staff must
complete the infection control e-learning package, as must members of the Corporate
Management Team.



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Monitoring of the IC Training is through the MLE. Training records are presented
quarterly at the IC Group. Audits and general IC practices are monitored in this Group.
Where gaps are established through this process, actions are taken to rectify.

Infection Control training comprises of:
 Core induction for all staff on employment
 New employees attend AWP induction. This includes core information on IC, hand
    hygiene, spread of infection and MRSA
 Medical Staff / SHO induction – completion of e-learning IC module and core induction
 Clinical staff receive during week 1 of employment: Introduction into IC Policies,
    including Universal Precautions and Sharps Management & Disposal and Inoculation
    incidents.
 including universal precautions and sharps management & disposal and inoculation
    incidents
 Infection control training during MOT days. One hour session includes HCAI/MRSA/C
    Diff, Waste Management, Hand Hygiene, Standard Universal Precautions including
    PPE, Outbreak Management, Transmission of Infection, Sharps Safety including
    disposal and inoculation incidents, Decontamination / Medical Devices / Cleaning /
    Spillages / Single use items, Management of Linen, Legionella, Antibiotic Prescribing,
    Specimen Collection.
 IC Principles Course provided by UWE. 10 day course, level 3, 20 CAT points. Three
    courses annually, available to all staff.
 Hand Hygiene training for all staff included in all training sessions. Light boxes are
    available on each in-patient site and hand hygiene training can be provided locally
    by ICLPs and Modern Matrons.
 Light boxes are available in each in-patient site and Hand Hygiene training provided
    locally by ICLPs and Modern Matrons – minimum annually.
 Infection control Link Practitioners are provided with infection control training
    packages for presentation locally
 Infection Control Link Practitioners complete NHSU IC e-learning package
 Infection Control Link Practitioners are provided with education session quarterly and
    must attend 3 out of 4 annually
 IC e-learning modules can be accessed via the Managed Learning Environment
    (MLE).
 Non e-learning training is recorded by Training Department and also accessed by
    MLE.


11. Decontamination

Effective decontamination is crucial to the success of this infection prevention and
control strategy. Decontamination includes the decontamination of medical devices,
other equipment, and environmental cleaning. The use of invasive equipment within the
Trust is extremely limited and this is a comparatively low area of risk for the Trust. The
Trust‟s approach towards decontamination is as follows:
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    Single use items will be used wherever possible. Reprocessing of devices
     designated for single use only is not permissible.
    Ensuring reusable medical devices are decontaminated in an accredited sterile
     services department that are registered and have the facilities and expertise to
     ensure that they are properly decontaminated. SLA agreements with local District
     General Hospital CCSD Departments provide this service.
    There are no In-house automated cleaning devices.

For items requiring manual decontamination, the Trust adopts the following approach:

    Ensuring staff must be properly trained and supervised whilst conducting cleaning
     duties.
    Providing gloves, personal protective equipment, and eye protection for staff and
     requiring that these be worn.
    Ensuring appropriate and dedicated equipment/receptacles are used for cleaning,
     e.g., clean utility
    Requiring staff to follow the instructions provided by the device manufacturer,
     including the choice, use and compatibility of decontaminants and the dismantling
     and reassembly of instruments.
    Discourages splashing and the generation of aerosols.

The Trust has a cleaning policy in place that sets out clear standard and expectations in
respect of cleanliness, which should be read in conjunction with this policy.
Environmental PEAT audits are completed minimum of annually by the Facilities Lead
and monitored by the IC Team via the IC Group. A separate Environmental Infection
Control Audit is completed at the same time and recorded through a central database.
Decontamination of Medical Devices is completed within the Medical Devices Audit.

12. Performance Monitoring

The Trust will establish key performance indicators for infection prevention and control
and closely monitor performance through the use of the balanced scorecard. The
balanced scorecard will be reported to the Board on a quarterly basis. The current
indicators are:


  No Key Indicator                               Standard          Mar 08          Oct 08        Mar 09
 1     Full compliance with                    HCC 2007           100%             100%          100%
       Standards for Better Health                               compliance       compliance    compliance

 2     Full compliance with the DOH  DOH 2006                     100%             100%          100%
       Health Act 2006 publication   Trust priority             compliance       compliance    compliance
 3     Alert Organism surveillance             DOH 2003       Awaiting targets     100%          100%
       is undertaken and monitored,            DOH 2004                          compliance    compliance
       including C Diff targets

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  No Key Indicator                               Standard           Mar 08          Oct 08          Mar 09
 4     Objectives within each                  Comprises          100%             100%            100%
       annual IP& C programme are               all standards    compliance       compliance      compliance
       monitored and completed                  listed
       within proposed timescales              Trustwide
                                                priority
 5     Continuous improvements in              DOH 2006         Roll out of      Benchmark      5% increase in
       hand decontamination                    DOH 2003        National Hand     audit result    compliance
       practices are demonstrated              NHSLA 2004        Hygiene
                                               NPSA 2004        Campaign
                                               Trustwide
                                                priority
 6     Continuous improvements in              DOH 2006            Present          Audit         Benchmark
       environmental hygiene and               DOH 2003          Compliance       prepared        compliance
       decontamination of                      NHSE 2001             level                      level achieved
       equipment are observed                  DOH 2004        to be confirmed
       utilising the ICNA audit tool.          NHSE 2004
                                               Trustwide
                                                priority
 7     To attain 100% compliance               NHSE 2000          100%             100%            100%
       with the NHSE Controls                  Trustwide        compliance       compliance      compliance
       Assurance Standards                      priority

13. Summary

The Infection Prevention and Control strategic plan 2008-09 describes and provides a
process through which the achievement of clearly defined performance targets will be
demonstrated.

Significant consideration is given to the national priorities and healthcare standards
against which the Trust‟s performance will be continuously assessed.

The success of the strategy is reliant upon support and ownership by the Trust both
corporately and operationally in addition to our key healthcare partners and
stakeholders. The Infection Prevention and Control team will lead and monitor the
implementation of the programme and report upon progress.

Finally, it is recognised that the infection prevention and control programme must
remain a dynamic and flexible document and will be subject to change/amendment in
accordance with local and national priority.




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References

DOH (2006) the Health Act code of practise for the Prevention and Control of
Healthcare Associated Infections

DOH (2004) Towards Cleaner Hospitals, July 2004.

NHS Estates (2001) National Standards of Cleanliness in Hospitals. DOH

NPSA (2004) cleanyourhands Campaign. DOH

DOH (2002) Getting ahead of the Curve: A Strategy for Combating Infectious Diseases

CMO (2003) Winning Ways Dec 2003. DOH.

NHS Estates (2004) A Modern Matrons Charter: An Action Plan for Cleaner Hospitals
DOH

NHSLA (2004) CNST Clinical Risk Management Standards. DOH

The Health & Safety at Work Act 1974

The Control of Substances Hazardous to Health Regulations 2002 and Approved Code of
Practice

DOH (2004) Standards for Better Healthcare

NHSE (2000) Control Assurance Standards DOH

NAO (2004) Improving care by reducing the risk of hospital-acquired infection: A
progress report. NAO London


Appendices

    Terms of Reference of Infection Prevention and Control Group
    IC Training Matrix
    Integrated Governance Structure




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             INFECTION PREVENTION AND CONTROL GROUP

                                        TERMS OF REFERENCE
OVERVIEW
To oversee the strategic development, provide advice, monitor progress of and report upon
the prevention and control of infection performance within Avon and Wiltshire Partnership
NHS Trust. Taking account of the specialist needs of the Trust in providing infection
prevention and control services to corporate and strategic business units. The focus will be
on compliance with the Department of Health „Health Act 2006‟ (Revised Jan 2008) Code of
Practice for the Prevention and Control of Healthcare Associated Infections and Standards
for Better Health. To ensure the Trust complies with these requirements the terms of
reference have been reviewed. In addition, the changing nature of the NHS necessitates an
evolving and adaptable model of approaching infection prevention and control issues.

AIM

To achieve full compliance with the Health Act Code of Practice on Healthcare
Acquired Infections 2006 and Standards for Better Health across the Trust by:

    Maintaining a strategy to ensure a clear systematic approach to all infection
     prevention and control work, which is of high quality, best practice and takes into
     account specialist Mental Health services
    Developing and monitoring Key Performance Indicators and associated action plan
     for performance improvement
    Alerting Integrated Governance where full compliance will not be achieved
    Working with nominated SBU Directors/Clinical Directors to ensure full
     implementation and monitoring of Trust Infection Control strategy and activity
    To work in partnership with and monitor infection control services provided by the
     Acute General Trusts, the Health Protection Agency and other outside agencies

REPORTING ARRANGEMENTS

    To Safety Forum on a quarterly basis, to include an annual assurance report in July
    To maintain a risk register and report accordingly
    Produce a Trustwide Annual Assurance Report




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MEMBERSHIP

Core members:

     Director of Integrated Governance & Nursing (Chair)
     Director of Infection Prevention and Control (Vice Chair)
     AWP Infection Control Team
     Nominated Infection Control Lead from each SBU or a representative.
     Assistant Director of Nursing (Medical Devices) or a representative.
     Trust Medical Director or representative
     Facilities Lead or a representative
     User Carer Forum representative

Co-opted Members:

     1 Health Protection Agency representative
     1 Infection Control representative from SLA provider. Invited individually on
     rotational basis

And where relevant other specialists will be invited as below:

     Pharmacist
     Learning and Development representation
     Infection Control Nurses
     Occupational Health representation from ATOS
     Staff side representation

CHAIR

    The meetings will be chaired by Director of Integrated Governance and in their
     absence by the Vice-Chair

MEETINGS

    Meetings will be held quarterly at Jenner House 2pm – 4pm.
    A quorum will require attendance by the Chair, or Vice-Chair and four members of
     the committee, including two SBU representatives and an Infection Control Nurse
    Simple majority voting of core members will take place if required. The Chair has
     the casting vote in the case of equal voting
    Organization of the meetings and minutes of the meetings will be taken by the PA to
     the DIPC and distributed within 2 weeks of the meetings




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GUIDANCE RELATING TO THE ROLE OF THE COMMITTEE

    The infection control group will act in accordance with relevant legislation, national
     and local guidance and best practice.
    The infection control group will act in accordance with the following specific
     legislation, policies and guidance:

               Winning ways DOH 2003
               Standards for Better Health
               The Health Act 2006 Code of practice for the prevention and Control of
                Healthcare Associated Infection
               Essential Steps to safe clean care DOH 2006
               DOH (2004) Towards Cleaner Hospitals, July 2004
               NHS Estates (2001) National Standards of Cleanliness in Hospitals

TERMS OF REFERENCE

    TOR will be reviewed annually and approved by IC group and safety forum



Approved Date ………………………………………..


Review Date               ………………………………………..




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INFECTION CONTROL TRAINING MATRIX



Attached separately




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                                                                                        Integrated Governance System

                                                                                                                                          Executive Management
                                                                                                        Trust Board
                                                                                                                                                  Team


                                                                                                                      Professional Council


   Assurance
    Strategic                    Audit and Assurance               Mental Health Act                Integrated Governance                           Finance & Performance    Remuneration
Framework, and                                                                                            Committee                                                                            Charitable Funds
                                      Committee                      Committee                                                                            Committee          Committee
     Policy
 Development


                                Patient Experience,
                                                                                                                                                                 Modernisation &
                                  Environment &                               Effectiveness                                      Safety
                                                                                                                                                                   Workforce
                               Partnership IG Forum                             IG Forum                                       IG Forum
                                                                                                                                                                   IG Forum

                                                                                              Relevant S4BH                                                                     Relevant S4BH
                                                    Relevant S4BH
                                                                                           Clinical Effectiveness                           Relevant S4BH                         Workforce
                                                   Privacy & Dignity
                                                                                               Clinical Policy                               Clinical Risk                     Staff Involvement
                                                   Food & Nutrition
                                                                                                    NICE                                     Environment                     Consent/Confidentiality
                                                  PALS/Complaints
                                                                                                    ICPA                                    Health & Safety                           IM&T
                                                          PPI
Executive Director                                                                       Research & Development                              Safeguarding                   Human Resources/JTCC
                                                User/Carer Involvement
 & SBU Service                                                                            Medicines Management                             Serious Untoward                      Sustainability
                                                  Patient Information
Director Co -Chair                                                                           Health Promotion                                  Incidents                            Diversity
                                                 Partnership Learning
of each IG Forum                                                                               Clinical Audit                             Emergency Planning                  Education & Training
                                                     Health OSC
                                                                                                     ECT                                        Estates                         Organisational
                                               Section 75 Arrangements
 Clinical Director                                                                           Essence of Care                                                                     Development
                                                    PEAT & ERIC
 From each SBU
of each IG Forum                                                                               Clinical Standards                       Health, Safety & Fire               Learning & Development
                                                                                                Standing Group                                   SG                                  Forum
  User & Carer
 Involvement in                                                                                                                              Clinical Risk SG
   IG Forums                                                                              Medicines Governance                                                                      IMSG
                                                                                                                                               Security SG

                                                                                         ICPAStanding Group
                                                                                              Standing Group                                                                Diversity Steering Group
                                                                                                                                         Infection Control SG

                                                                                              Trust Psychological
                                                                                               Therapies Forum                               Safeguarding SG


                                                                                                                                    Secure Services SBU               Specialist Drug & Alcohol
                       CAMHS SBU                          Older Adult                              Adult SBU
                                                                                                                                     Governance Team/                 Service SBU Governance
                     Governance Team                   Governance Team                          Governance Team
                                                                                                                                          Groups                                Team
     SBU
Implementation


                                                         Older Adult                               Acute Care                        Heads of Profession
                                                           Forum                                     Forum
                                                                                                                                                                                                       Last Updated
   Clinical                                                                                                                                                                                             July 2007
  Networks
                                                                                            -ordination Up Down and Across
                                                                 Two Way Communication and Co             ,

				
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Description: Infection Control and Decontamination Strategy