TRUST BOARD
SEPTEMBER 2012
ANNUAL INFECTION CONTROL PLAN
Purpose:
For Ratification
Author:
Mary Ayton, Lead infection control Nurse
Lead Director:
Christopher Tibbs, Medical Director
EXECUTIVE SUMMARY
The plan lays out the framework and objectives of the Trusts infection control strategy for the
current year
1.
INTRODUCTION
For compliance with The Health and Social Care Act 2008, the Trust needs to meet Outcome 8
of the Care Quality Commission (CQC) registration requirement for cleanliness and infection
control: People should be cared for in a clean environment and protected from the risk of
infection.
2.
MAIN CONSIDERATIONS
2.1. Surveillance: To undertake surveillance which is compliant with national requirements
and designed to achieve reduction in HCAI Audit of compliance with infection control
measures and establishments of tolerance limits for 2012-13
2.2. Audit: Monitor compliance with IC Policies/Guidance through the IC Audit Programme
2.3. Training: Providing educational IC framework for all HCWs through adherence to the
statutory and mandatory training policy
2.4. Policies and Guidelines: To maintain and enhance IC Policy and Guidance to include
national standards and local results with audit and monitoring reports Maintaining a
contemporary and up to date set of infection control policies
2.5. Decontamination: To comply with National and EU regulations
2.6. Cleanliness: To comply with national guidance on cleanliness standards and provide
patients and visitors with a clean hospital environment
2.7. Antibiotic prescribing: To promote prudent antimicrobial prescribing for the
management of antibiotic resistance and reducing antibiotic related CDI and other HCAI
2.8. Estates: To ensure hospital premises are designed and built to facilitate the prevention
and control of infection
3.
RISK MANAGEMENT IMPLICATIONS RELATIONSHIP WITH ASSURANCE FRAMEWORK
Integral requirement of CQC and NHSLA standards and compliance with legislation
4.
CONCLUSIONS and RECOMMENDATIONS
The Infection control plan sets out the appropriate actions to maintain a clean and safe
environment in the Trust and to minimise the risk of infection to patients and staff
The Trust Board is recommended to ratify this plan.
RSCH Infection Control Plan 2012-13
For compliance with The Health and Social Care Act 2008 The Trust needs to meet Outcome 8 of the Care Quality Commission (CQC) registration
requirement for cleanliness and infection control: People should be cared for in a clean environment and protected from the risk of infection.
Objective
Action
Timescale
Lead
Surveillance -
MRSA bacteraemia (MRSAB)
April 2012- March 2013
Mary Ayton
To undertake surveillance
which is compliant with
national requirements and
designed
to
achieve
reduction in HCAI
DH Objective for 2012-13 = 1
Reported monthly to HPA via the HCAI
data capture system (DCS)
RCA for all cases
Christopher Tibbs
MSSA bacteraemia (MSSAB)
April 2012- March 2013
Mary Ayton
No objective set
Reported monthly to HPA via the HCAI
DCS
RCA for RSCH apportioned cases
Christopher Tibbs
Clostridium difficile (CDI)
April 2012- March 2013
DH Objective 2012-13 = 22
RSCH Internal Objective 2012-13 = 15
Reported monthly to HPA via HCAI DCS
RCA for RSCH apportioned case or death
Mary Ayton
Christopher Tibbs
Progress
Objective
Action
Timescale
Lead
E-coli bacteraemia
April 2012- March 2013
Mary Ayton
January June 2012
Mary Ayton
Ongoing
Marian Hunt
April 2012- March 2013
Christopher Tibbs
No objective set
Reported monthly to HPA via the HCAI
DCS
GRE positive blood cultures
Progress
No objective set
Reported quarterly to HPA via HCAI DCS
Monthly provision of HCAI data
Feedback and communication via TrustNet and
G:\Shared\TrustWide\INFECTION
CONTROL
TEAM FOLDER (Managed by ICT)\HCAI Monthly
Surveillance Data
Outbreaks/Incidents
Convene and minute Outbreak/Incident Outbreak
Meeting in liaison with Head of Patient Safety &
Quality, providing reports to commissioning and
monitoring groups as required
Objective
Action
Audit
Saving Lives
Monitor compliance with
IC
Policies/Guidance
through the IC Audit
Programme
Minimum
Compliance
Hand Hygiene
89%
Bare Below the Elbows (BBE)
88
Environment
80
Central VAD Insertion
93
Central VAD Care
90
Peripheral VAD Insertion
73
Peripheral VAD Care
83
Uretheral Catheter Insertion
72
Uretheral Catheter Care
82
Clostridium difficile (CDI)
74
SSI
92
VAP
90
Timescale
Lead
April 2012- March 2013
Helen Collins
Progress
Objective
Action
Timescale
Lead
April 2012- March 2013
Gill Hickman
Ongoing
Mary Ayton
Providing educational IC Infection Control Team will support a single
framework for all HCWs Infection Control Programme (100% compliance)
through adherence to the
statutory and mandatory
training policy
Update
Ongoing
Mary Ayton
ICNA
Compliance %
PPE
85
Isolation Rooms
85
Patient Equipment 85
Training
Induction
Infection Control Team will support all clinical
and non-clinical staff working in clinical areas to
receive an annual Infection Control Update via
planned training sessions or e-learning modules
(85% compliance)
Doctors
Ongoing
All new junior doctors to receive local
competency assessments (LCAs) in Infection
Control at time of Induction as well as completing
IC e-learning training tracker.
Louise Duffield
Progress
Objective
Action
Timescale
Lead
Hand Decontamination
Ongoing
Mary Ayton
All staff including contractors and volunteers to
receive hand decontamination training
Adopt a zero tolerance approach through
challenging non compliance and use of DIPC zero
Ongoing
tolerance letters
Policy/Guidelines
Planned programme of review/updating with March 2013
adherence to the policy on policies
To maintain and enhance
IC Policy and Guidance to
include national standards
Hand Decontamination Policy to NHSLA level 2
November 2012
and local results with audit
standard
and monitoring reports
Decontamination
Opening of new compliant Endoscopy Unit
To comply with National Review/updating
and EU regulations
Policy/Guidance
of
October 2012
Decontamination
Christopher Tibbs
Gill Hickman
Mary Ayton
Robin Jago
TBC
November 2012
Progress
Objective
Action
Timescale
Lead
Cleanliness
Ensure compliance with
Ongoing
Janet Carr
March 2013
Janet Carr
Ongoing
Maria Rana
Ongoing
Dr Papu De
Ongoing
Graham Maynard
To comply with national
National monitoring of standards
guidance on cleanliness
Education of Housekeeping staff
standards and provide
Peer and Public review of service
patients and visitors with a
Support of peer and public reviewers
clean
hospital
Compliance with annual PEAT Inspection
environment
Monthly patient environment audits (MEAT)
Antibiotic Prescribing
Use of IC data in relation to HCAI to
promote antimicrobial policies
To
promote
prudent
antimicrobial prescribing
for the management of
antibiotic resistance and
reducing antibiotic related
CDI and other HCAI
Audit
Continual review of antibiotic use as part
of the Stewardship Programme
Estates
Monthly Estate Meetings to review all
new builds and refurbishments. Sign off
of plans and pre-opening build by ICT in
line with National guidance and practice
To
ensure
hospital
premises are designed and
built to facilitate the
prevention and control of
infection
Progress
