Download OCCG Core Policy 1 Infection Control Policy and Programme

INSERT PRACTICE NAME HERE
OCCG IPC Core Policy 1;
Infection Prevention Policy and Programme
Contents
1. Introduction
2. Statement from Practice Manager/Lead Doctor
3. Accountability and Responsibilities
3.1 Practice manager/Lead Doctor
3.2 Infection prevention lead
3.3 Decontamination lead
3.4 Individuals
3.5 Antimicrobial prescribing
3.6 Attached staff
3.7 Occupational health
4 Public Health England Centres
5 OCCG infection control team
6 Policies
7 Audit
8 Training and development
9 References
10 Appendix – example IPC Programme
Date issued: August 2016
Date for review: August 2019
3 yearly or earlier if new guidance published
Infection control programme
1
INSERT PRACTICE NAME HERE
OCCG Core Policy 1
Infection Prevention and Control Policy and Programme
1.
Introduction
1.1
All healthcare workers have a duty to minimise the risk of patients and staff
acquiring infection. The management and organisation of Infection Prevention
and Control of Health Care Associated Infections (HCAI) are set out in The Health
and Social Care Act 2008: Code of Practice for the NHS on the Prevention and
Control of Healthcare Associated Infections1.
1.2 This policy applies to all members of (name of practice). All staff, both clinical
and non-clinical are required to adhere to the (name of practice) Infection
Prevention and Control Policies and procedures and make every effort to
maintain high standards of infection control at all times thereby reducing the
burden of HCAI. This is an overarching policy and programme and is intended to
outline how (name of practice) will deal with the complex issues with regard to
infection prevention and control. It outlines the arrangements and responsibilities
of all staff concerned in the provision of health care.
1.3
The prevention and control of infection is a key priority for the NHS and
forms an important part of the (name of practice) Governance arrangements. The
(name of practice) is monitored by adherence to standards by NHS England.
1.4
This policy sets out the commitment of the (name of practice) in its
collective responsibility to minimise risks of infection and cross contamination
within the practice.
1.5
An annual programme of infection prevention & control will be written and
followed by the practice.
2
Statement by the Practice manager/lead doctor
2.1
Healthcare Associated Infections are not something that concerns only the
infection prevention and control lead or indeed only the clinical staff. Everyone
has a role to play in ensuring patient safety.
2.2
Prevention and Control of Infection is a core part of patient safety and our
governance system. As a practice we will ensure compliance with legislation and
national guidance for Infection Prevention and Control and cleanliness.
2.3
The practice will produce an infection prevention and control programme
that will include:




What infection prevention and control measures are needed in the
practice
What policies, procedures and guidance are required
What induction and ongoing training is required for all staff
The audit programme
Infection control programme
2
INSERT PRACTICE NAME HERE
3
Responsibilities
3.1
Practice manager/lead doctor
The Practice manager/lead doctor has the responsibility to ensure compliance
with legislation and national guidance for Infection prevention and Control and for
cleanliness1. This includes:
Appoint an Infection Prevention and Control Lead (IPC Lead)

Appoint a designated lead for cleaning and decontamination of the
environment and equipment (nb this can be the IPC lead)

Approval of an annual infection prevention and control programme

Policy, procedure and guidance approval

Appraise outcomes of action plans in relation to Infection Prevention
and Control
3.2




3.3



Infection Prevention and Control Lead
Advise the practice on the policies, procedures and guidance that are
required and how they are to be disseminated and kept up to date
Working with the practice manager to establish and facilitate the
training requirements of all staff in relation to infection control.
Prepare an annual statement and plan
Keep up to date on developments in infection control
Designated Decontamination lead
Prepare policies and procedures for decontamination of the
environment, equipment and reusable medical equipment
Set out the type of products are used for successful cleaning and
decontamination
Training required to achieve the above
3.4
Individuals
All staff have a responsibility to ensure they comply with local infection control
policies and procedures. They should demonstrate patient safety and well-being
as a priority within day to day activities. In particular:

Staff must wash their hands or use alcohol gel between each patient
contact

Staff members have a duty to attend infection control training provided
for them.
3.5
Antimicrobial Prescribing
All prescribers should adhere to;

The Oxfordshire CCG Prescribing Guidelines for the use of
Antimicrobial Agents in Primary Care9.2

The Oxfordshire CCG Antimicrobial Guidelines Policy Statement.

Document an indication and duration for each antimicrobial prescribed
in the patients notes.
Infection control programme
3
INSERT PRACTICE NAME HERE


Adhere to recommendations as described in the DoH UK 5 year
antimicrobial resistance strategy 9.3
Utilise toolkits such as the TARGET toolkit as recommended by
RCGP9.4
These guidelines are based on evidence and local resistance patterns and so
their prudent use will help to reduce the risk of infections from MRSA, Clostridium
difficile and other resistant bacteria.
Where sensitivities show a choice of antimicrobials, the one with the least risk to
predispose patients to infection with Clostridium difficile or MRSA should be used.
3.6
Attached staff
All staff attached to the practice have responsibility to ensure they comply with
local infection control policies and procedures. They should demonstrate patient
safety and well-being as a priority within day to day activities. In particular:

Staff must wash their hands or use alcohol gel on entry and between
each patient contact

Staff members have a duty to attend mandatory infection control
training provided for them by either the practice or their employer.
3.7
Staff Health
Any significant injury or infection acquired at work must be reported to the
Practice Manager and reported according to the practice incident reporting policy.
Sharps injuries involving bodily fluids must be reported to the practice manager
and the sharps injuries protocol must be followed.
4
Public Health England Centres (PHEC)
The Health Protection Teams lead the Public Health England response to health
protection related incidents. The team is comprised of Consultants in
Communicable Disease Control (CCDC), Consultants Health Protection (CHP)
and Health Protection Practitioners (HPPs and other supporting staff.
Outbreaks and incidents of infection in the community will be monitored and
investigated by the team and they will initiate and co-ordinate any necessary
action to limit further spread.
5
OCCG Infection Control advice
The OCCG infection control team is based at Jubilee House.

Lead for Infection Prevention and Control 01865 336856
6
Policies
Infection control programme
4
INSERT PRACTICE NAME HERE
Policies relating to Infection prevention and control will be monitored for
compliance through the annual audit. Policies will remain current for 3 years
unless guidance changes. The practice manager / IPC lead will be responsible for
reviewing the currency of policies.
7
Audit
An annual audit of infection control should take place. This can be a selfassessment or an invited team.
8
Training and Development
8.1
The practice will ensure provision of training to clinical staff to enable them
to carry out their duties and responsibilities relating to infection control this will
include hand hygiene and infection control processes and procedures. This
should occur on a 2 yearly basis.
8.2
The practice will ensure provision of training to non- clinical staff to enable
them to carry out their duties and responsibilities relating to infection control. This
should occur on a 2 yearly basis
8.3
9
Infection control will be included in new staff induction training.
References
Infection control programme
5
INSERT PRACTICE NAME HERE
9.1 Department of Health (2015) The Health Act 2008; Code of Practice for the
Prevention and Control of Healthcare Associated Infections. Department of
Health.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_122604
9.2 OCCG Prescribing Guidelines for the use of Antimicrobial Agents in Primary
Care
http://occg.oxnet.nhs.uk/GeneralPractice/ClinicalGuidelines/Infectious%20Diseas
es/Antimicrobials/Oxfordshire%20Antimicrobial%20ADULT%20Guidelines%20Pri
mary%20Care%20January%202016%20v2.3.pdf
9.3 DoH (2015) UK 5 year antimicrobial resistance strategy
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244
058/20130902_UK_5_year_AMR_strategy.pdf
9.4 TARGET toolkit
http://www.rcgp.org.uk/TARGETantibiotics/
9.5 Department of Health (2003), Winning Ways, Working together to reduce
Healthcare Associated Infection in England.
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandsta
tistics/publications/publicationspolicyandguidance/dh_4064682
9.6 NICE (2012) Healthcare associated infections; prevention and control in
primary and community care
https://www.nice.org.uk/guidance/cg139/chapter/1-guidance
Infection control programme
6
INSERT PRACTICE NAME HERE
10 Appendix Example IPC Programme
Practice annual infection control programme April (add year) –March (add year)
Patient safety is a key objective of the practice philosophy and preventing infections is integral to this. The practice
principle, medical, nursing and healthcare staff and all attached staff will work together to ensure an environment that is
safe and clean and patients are protected from identifiable risks of acquiring infections.
Objective
Action
Lead
Reporting
Outcome
frequency
There are systems to manage  There is an infection prevention
PM
and monitor the prevention
At practice
programme in place
and control of infection.
governance
 An annual audit will take place
PM/
meeting
 There is a nominated lead for infection
Practice
prevention and control.
IPC lead
 There are the appropriate polices
procedures and guidance in place to
Annual review
provide a clean, safe environment
 An annual statement will be presented
Practice
Annually (dateto the practice (date)
IPC lead
after April each
year)
There is a training programme
in place



Infection control programme
All new staff will have infection
prevention training as part of their
induction
All new staff will have hand hygiene
training
All clinical staff will have two yearly
infection prevention training which will
include hand hygiene training
Practice
IPC lead
and
Practice
manager
7
A record of training
will be kept and
reviewed every 6
months.
INSERT PRACTICE NAME HERE

The practice will provide a
safe, clean environment that
prevents and controls
infection.





There is a system in place that
keeps service users informed
of the practice approach to
infection prevention and
control

The practice will ensure that
information is shared between
healthcare providers on any
infection that a service users
may have (MRSA- C.diff etc)
Staff will be protected from
exposure to blood borne
viruses through immunisation,
safe management of exposure

Infection control programme

All non-clinical staff will have infection
prevention training every two years
There is a designated lead for cleaning
and environmental decontamination
There are documented cleaning
programmes that are accessible and
kept up to date
There is a record of staff trained to
carry out cleaning programmes
A monitoring programme is in place for
environmental cleaning
There is an annual audit of
decontamination processes
The PPG/PLG is kept up to date with
the approach the practice is taking to
keep them informed.
There is information available to
patients on infections and risks of
transmission (good hand hygiene, catch
it - bin it - kill it)
Ensuring confidentiality, any letters or
referrals to other organisations will have
relevant infection information included.



A policy is in place for staff to follow
There are posters in place for staff to
follow in the event of a sharps injury so
staff know what to do.
PM
Minimum annual
audit; bi-annually
preferable
Decontami
nation lead
Practice
IPC lead
and PM
Annual report
Clinical
and
medical
staff
PM and
Practice
IPC lead
8
Annual audit of
sharps and related
injuries and
outcome of
INSERT PRACTICE NAME HERE
and safe use and disposal of
sharps and
There is a local policy in place
for antimicrobial prescribing
and a system of audit is in
place.

Waste is managed and
complies with the National
Waste Guidance


Environment. NOTE : Any
information in relation to
improving the practice
environment to comply with
the Code of Practice can be
put in here. This could be
refurbishment, rebuild, new
equipment etc. and how the
Infection control is factored
into the build.
Infection control programme






This above will be checked as part of
the infection control audit cycle
All prescribers have access to the local
prescribing guidelines
An audit plan is in place.
The practice reviews prescribing
patterns and quarterly details sent by
PCT.
All waste is appropriately labelled
Staff are trained to comply with waste
systems
A waste audit carried out
Development of risk register for practice
Replacement programme for damaged
equipment
response. Detail in
the annual report
Prescribing
lead
PM
PM and
Practice
IPC lead
9