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Infection prevention and Control Policy Page: Page 1 of 33

Author: Head of Clinical Safety Version: 6.0

Date of Approval: March 2014 Status: Final

Date of Issue: April 2014 Date of Review April 2016

Infection Prevention and Control

Policy

Infection Prevention and Control Policy Page: Page 2 of 33

Author: Head of Clinical Safety

Version: 6.0


Date of Issue: March 2014 Date of Review April 2016

Recommended by Clinical Governance Management Group

Approved by Quality Committee

Approval date March 2014

Version number 6.0

Review date April 2016

Responsible Director Director of Quality

Responsible Manager (Sponsor) Head of Clinical Safety

For use by All Trust employees

This policy is available in alternative formats on request.

Please contact the Clinical Safety Team

On 01228 403000



Version: 6.0



Change record form

Version Date of change Date of release Changed by Reason for change

x 0 Jan – Mar 2007 08 March 2007 D. Bullock Document Creation

x 0.1 08 March 2007 09 March 2007 H. Lambert Revised Draft

x 1 16 March 2007 21 March 2007 N. Barnes Revised for submission to Trust

Board

x 1 28 March 2007 2 April 2007 N/A Approved by Trust Board

x1.1 October 2007 October 2007 D. Bullock Reviewed Draft

x 1.2 October 2007 October 2007 H. Lambert Revised Reviewed Draft

x 1.3 Oct – Dec 2007 17 Dec 2007 D. Bullock Revised Reviewed Draft

x 1.4 20 Dec 2007 20 Dec 2007 N. Barnes Revised Reviewed Draft

x 1.5 31 Dec 2007 31 Dec 2007 D. Bullock Revised Reviewed Draft

x 1.5 9 Jan 2008 9 Jan 2008 N/A Approved by Clinical Governance &

Safety Sub committee

x 1.6 14 Jan 2008 14 Jan 2008 D. Bullock Revised for submission to Trust

Board

x 2 17 Jan 2008 17 January

2009 N Barnes

Revised for submission to Trust

Board

x 2 30 Jan 2008 01 February

2008 N/A Approved by Trust Board

x 2.1 18 Sept 2009 18 Sept 2009 D Bullock Revised for submission to EMT

x 3 21 Sept 2009 21 Sept 2009 N Barnes Revised for submission to Trust

Board

X 3 30 Sept 2009 1 October

2009 N/A Approved by Board of Directors

X 4 15th September

2010

6th October

2010 D Bullock

Revised for submission to EMT and

Board



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X 4 15th October 27th October

2010 D Bullock Board Approved Document

X4.1 March 2012 5th April 2010 D Bullock

Reviewed in line with new

documentation and other new

policies. For CGMG approval.

X 4.2 15th April 2012 18th April 2012 D Bullock Reviewed following further

feedback

X 4.3 18th April 2012 23rd April 2012 D Bullock

Approved at GCMG – reviewed for

approval at EMT and Quality

Committee

X 5 24th April 2012 14th May 2012 N/A Approved Quality Committee May

2012 version 5.0

X5.1 19th February

2014

25th February

2014 D Bullock

Updated policy revision for Quality

Committee approval

6.0 6th March 2014 1st April 2014 D Bullock Approved by Quality Committee

March 2014 Version 6.0



Version: 6.0



Infection Prevention and Control Policy Contents

1.0 Policy Statement 5

2.0 Introduction 6

3.0 Scope 7

4.0 Objectives 8

5.0 Aims 8

6.0 Organisational Framework 9

7.0 Responsibilities and Duties 9

8.0 Education and Training 17

9.0 Assurance and Compliance 17

10.0 Monitoring 18

11.0 Audit 20

12.0 Information Sharing 21

13.0 Equality and Diversity 22

14.0 Document Development and Review 22

15.0 Related Policies and Procedures 22

16.0 References 23

17.0 Implementation and Monitoring 23

Appendix 1 Equality Impact Assessment 25



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1.0 POLICY STATEMENT The North West Ambulance Service NHS Trust (‘NWAS’ or ‘the Trust’) is committed to promoting the highest standards of infection prevention and control to ensure that appropriate measures are in place within the Trust to reduce the risk of acquired infections and therefore increase the safety of our patients, staff and the public. The Trust Board is fully committed to addressing the risks of healthcare associated infection and serious communicable diseases, through a policy aimed at dealing proactively with the outcomes and continually developing safer working practices. The North West Ambulance Service NHS Trust recognised that the Health and Social Care Act 2008 introduced a statutory duty on NHS organisations to observe the provisions of the Code of Practice on Healthcare Associated Infections. As a result the Trust Board has reviewed its arrangements and is assured that it has suitable systems and arrangements in place to ensure that the Code is being observed at this Trust. Although the Trust does not contribute to the National HCAI performance and quality monitoring data collection for MRSA infections and Clostridium Difficile we are fully committed to reducing all HCAI. All IPC procedures reflect this aim to have a zero tolerance to HCAI. The Trust actively investigations into all HCAI by other health organisations and an active Infection Control Action plan in place engages with the processes for HCA/ Infection prevention and control (IPC) as members of IPC health groups across the region. This includes involvement in root cause analysis. The Board can confirm that it meets the requirements for the Annual Health Check as stated in the Care Quality Commission criteria for the prevention and control of infections. The Trust acknowledges that the provision of appropriate training is central to the achievement of this aim. This document applies to all employees of the Trust with active lead from managers at all levels to ensure that infection prevention and control is a fundamental part of the total approach to quality. Copies of the policy will be available on all sites. This policy will also be shared with external stakeholders and where appropriate expert advice will be sought. Signed by:

B Williams S Faulkner Chief Executive Director of Quality (DIPC)



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Date: March 2014

2.0 INTRODUCTION The purpose of the North West Ambulance Service NHS Trust (‘NWAS or the Trust’) Infection Prevention and Control Policy is to minimise risks associated with the control of infection and to provide the Trust Board with an effective approach towards providing a safe, clean and modern environment. It will also provide safe working conditions and best practices for staff and the patients within their care. The policy has been produced to ensure NWAS commitment to promoting the highest standards of infection prevention and control within the organisation. The policy and requirements for addressing the management of infection prevention and control has been developed in line with the following:

The Health and Social Care Act 2008: Code of Practice for the NHS on the Prevention and Control of Health Care Associated Infections and related guidance (Department of Health; January 2009)

Ambulance Guidelines; Reducing infection through effective practice in the pre-hospital environment (Department of Health; June 2008)

The National Specifications for Cleanliness in the NHS: a framework for setting and performance measuring performance outcomes in ambulance trusts (National Patient Safety Agency: 2008)

NCGC NICE Clinical Guideline 2 – Infection Prevention and Control of HCAI in primary and community care March 2012

National Waste Management regulations (DOH 2010)

Uniforms and Work wear: an evidence base for developing local policy (Department of Health: March 2010)

Managing Healthcare Associated Infection and Control of Serious Communicable Diseases in Ambulance Services (Ambulance Service Association; November 2005).

NHSLA risk management standards for Ambulance Trusts.

Department of Health’s Essential Steps to Safe, Clean Care.

IPC Commissioning Toolkit- Zero Tolerance of HCAI March 2013

EU Directive 2010/32/EU (the Sharp Directive)

Health & Safety (Sharp Instruments in Healthcare) Regulations 2013

Immunisation Against Infectious Disease: The Green Book; (Public Health England 2013)

All NHS Trusts have a statutory duty to comply with The Code, which stipulates; “so far as reasonably practicable, patients staff and other persons are protected against risks of acquiring healthcare acquired infections (HCAI’s) through the provision of appropriate care, in suitable facilities, consistent with good clinical practice”



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The policy has associated procedures relating to the minimising of risks associated with the control of infection. These procedures reflect current ‘best practice’ within the modern health care profession and have been validated by external specialists of infection prevention and control at the Health Protection Agency. Generic and specific risk assessments are included within the Trust’s risk registers. The Infection Prevention and Control Policy and Procedures adopt routine protection measures known as ‘Standard Precautions’ which are based upon treating every patient as if they are a potential source of infection. These precautions will minimise a large area of risk from infection, since the ambulance service will not know with the vast majority of patients, if there is an infection risk. There is a separate NWAS Communicable Diseases Policy which addresses outbreaks of unusual illness and their management. This can be found on the Intranet and on Stations. The Trust supports in principle the Department of Health research which has led to healthcare organisations adopting a ‘bare below the elbows’ policy to reduce the risk of infection from contaminated sleeves, watches and jewellery. Prior to the commencement of a shift operational staff (Paramedic Emergency Services and Patient Transport Service) will be expected to remove all wrist and hand jewellery (wedding band and jewellery worn for cultural religious reasons is excluded). The Trust actively promotes an open and fair culture and encourages incident reporting. The organisation believes that learning can only take place if incidents are reported, it is imperative that the incident reporting system is used to allow for proactive as well as reactive risk management of healthcare associated infection. The Trust supports Equality and Diversity and an Equality Impact Assessment of this policy has been undertaken. Results of this Assessment can be found at Appendix 1. The Trust is committed to ensuring that all staff with responsibility for infection prevention and control and those who are exposed to healthcare associated infection or serious communicable diseases receive the appropriate level and content of training. Refresher training for staff and relevant information detailing changes made will also be undertaken as and when required.

3.0 SCOPE This Policy aims to ensure that all risks associated with the control of healthcare associated infections including inoculations are adequately controlled. This Policy applies to all relevant personnel employed by or that come into contact with NWAS including patients, the public, contactors and voluntary staff.



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The Health & Safety at Work Act 1974 places general duties upon all managers, employees, and suppliers of goods relating to health, safety and welfare. The introduction of the Management of Health and Safety at Work Regulations 1999 and The Control of Substances Hazardous to Health Regulations 1999, make more specific those duties placed upon Managerial Staff towards staff in their care and the protection of its workforce from infection risks, and any third parties who may be affected by the Trust’s undertakings. Chemical, Biological, Radiological and Nuclear (CBRN) risks require specialist advice and training. The Department of Health provides this information and the Trust has a team of specialists who are trained to deal with these risks. The key principles contained within this policy are relevant to CBRN activities within the Trust, however the Resilience Team are responsible for providing policies, procedures, training and risk assessments relating specifically to CBRN. All procedures and relevant information relating to Infection Prevention and Control are available as a separate document. These can be found on all stations and on the Trusts intranet site.

4.0 OBJECTIVES

To confirm that the Trust’s commitment to the control of infection and to set the strategic direction for infection prevention and control initiatives.

To provide a clear and comprehensive policy in order to assure infection prevention, control and decontamination arrangements throughout the Trust.

5.0 AIMS NWAS aims to fulfil its duties to its employees by:

Encouraging staff at all levels to adopt responsibility for their own safety and that of others who may be affected by their acts or omissions.

Ensuring that relevant staff are aware of how cross infection occurs and the steps they, as an individual must take to adequately control such risks.

Ensuring that relevant staff at all levels receive training to the best current information regarding infection prevention and control, enabling them to be fully conversant with the risk to themselves and where appropriate, to the patients in their care.

Providing relevant staff with clear work procedures and safe systems of work wherever applicable.



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Ensuring that relevant staff have access to any personal protective equipment to help reduce the risk of infection and that they are trained to correctly use, clean, store and dispose of such equipment.

Ensuring staff are aware of techniques to ensure good personal hygiene.

Ensuring relevant staff are aware of techniques required to adequately clean and where necessary disinfect equipment and vehicles.

Ensure that the Trust actively promotes an open and fair culture and encourages incident reporting and full investigations into IPC incidents so that lessons can be learned and infection risks reduced.

ORGANISATIONAL FRAMEWORK 6.1 Infection Prevention and Control Forum Infection prevention and control will be monitored through the Infection Prevention and Control Forum which aims to provide a robust mechanism for assuring infection prevention and control arrangements, providing advice on hygiene, infection prevention and control matters and establishing a framework for developing improvements in order to optimise patient care and staff safety. The IPC Forum will be chaired by the Head of Clinical Safety and will meet on a quarterly basis. It reports through to the Trust Board via the Clinical Governance Management Group and Forum membership will comprise of appropriate management representation, staff representation and an internal/external advisor on Infection Prevention and Control. 6.2 Clinical Governance Management Group The Clinical Governance Management Group will oversee all areas of infection prevention and control within the Trust and will provide advice to the Trust Board to ensure that the Trust has working practices and appropriate systems in place to ensure effective infection prevention and control management. The Clinical Governance Management Group will ensure that the Trust is compliant with current legislative and national guidance and where necessary seeks external specialist infection prevention and control advice.

7.0 RESPONSIBILITES AND DUTIES It is the responsibility of all NWAS employees to be familiar with the policy and procedures, and to adhere to them at all times.



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7.1 The Trust Board The NWAS NHS Trust Board is committed to and responsible for the control and prevention of infection. The Trust Board will ensure that by ensuring appropriate management systems for infection prevention and control of infection are in place, patients, staff and other persons are protected against risks of acquiring healthcare associated infections through the provision of appropriate care, in suitable facilities, consistent with good clinical practice. 7.2 Chief Executive Officer The Chief Executive of the Trust has overall statutory responsibility. It is the Chief Executive’s responsibility to ensure the delegation of this responsibility to the Trust’s Medical Director. As per ‘The Health and Social Care Act 2008’ the Trust has a duty to establish management arrangements for infection prevention and control. As such the Trust’s Chief Executive Officer has nominated the Trust’s Director of Quality as the Director for Infection Prevention and Control (DIPC) and is therefore, directly accountable to the Trust Board. 7.3 Director of Quality (DIPC) It is the responsibility and role of the Director of Quality (DIPC) to:

Report directly to the Chief Executive Officer, Executive Management Team (EMT) and the Trust Board to ensure that any changes in legislation or national guidance relating to infection prevention and control are made known to the organisation.

Assess the impact of all existing and new national guidance, policies and/or procedures on HCAI and make recommendations for change.

Oversee NWAS control of infection related policies and their implementation.

Ensure that the Trust provides adequate resources to secure effective prevention and control of healthcare acquired infections.

Ensure that the Trust implements an appropriate infection prevention and control infrastructure and infection prevention and control programmes.

Ensure that appropriate actions relating to the prevention and control of infection are taken following recommendations from the EMT or Trust Board.

Ensure that the Trust Board receives regular reports (including key performance indicator reports) with regards to infection prevention and control issues.



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Produce an Annual report on Infection Prevention and Control within the Trust as a public document as part of the annual Quality Report. Be an integral member of the Trust’s Clinical Governance and Clinical Safety teams and structures.

Ensure that any recommendations made by the appropriate NWAS Groups and Forums are actioned and appropriately communicated within the Trust.

Be responsible for the infection prevention and control team (IPCT) within the Trust.

Have authority to challenge inappropriate clinical hygiene practice. 7.4 Director of Operations

The Director of Operations will have overall responsibility for the decontamination and cleaning of ambulance vehicles and reusable equipment for Service Delivery in line with relevant national guidelines and ensure that there are associated cleaning schedules accessible to be seen by staff and the public. 7.5 Head of Patient Transport Service The Director of Patient Transport Service will have overall responsibility for the decontamination and cleaning of ambulance vehicles and reusable equipment for Patient Transport Service services and to ensure that there are associated cleaning schedules accessible to be seen by staff and the public. 7.6 Executive/Senior Directors:

Ensure the principles of the Trust’s Infection Prevention and Control Policy and Procedures are adhered to within their own area of control.

Ensure that all area /directorate issues are reported appropriately throughout the Trust.

7.7 Assistant Quality Director

Responsibility for managing and co-ordinating all relevant infection prevention and control activities and requirements of the Trust.

Responsible for co-ordinating the annual review of the Trust’s Infection Prevention and Control Policy.

7.8 Assistant Director for Estates and Fleet:



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Responsible for liaising with the Assistant Quality Director and Service Delivery Managers to ensure that all environmental policies and estate management procedures are compliant with IPC best practice.

Responsible for ensuring that all premises are fit for purpose and maintained to support good infection prevention and control practice.

7.9 All Assistant Directors:

Responsibility for ensuring adherence to the elements of infection prevention and control policy and procedures relevant to their own areas of control.

7.10 Head of Clinical Safety:

Development of Trust wide Infection Prevention and Control Policy and Procedures compliant with legislation and ‘best practice’.

Monitoring compliance with infection prevention and control policies and procedures across the Trust.

Ensuring any necessary revisions are undertaken to meet statutory, mandatory and Trust standards.

To ensure communication to the appropriate Group of the Trust Board regarding infection prevention and control issues.

Responsibility for ensuring the consistent working of the Infection prevention and Control Team.

Ensure the provision of appropriate training with regard to infection prevention and control.

To ensure that there is a communication mechanism in place for staff at all levels with regard to infection prevention and control issues including infection prevention and control incident reporting.

To ensure that the Clinical Safety Team in conjunction with Service Delivery completes audits regarding infection prevention and control.

Development and implementation of annual infection prevention and control plan and annual report.

Co-ordination of infection prevention and control management across the Trust and development of performance management framework (Clinical Safety Indicators).



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Provision of advice and support in relation to infection prevention and control issues by liaison with Public Health England..

Responsibility for initiating a periodic review of infection prevention and control activities and making appropriate recommendations to ensure that the Trust maintains a current and valid infection prevention and control policy.

Monitors and reports on any investigations in relation to HCAI incidents which the Trust may have been involved in and asked to investigate by other health organisations.

7.11 Clinical Safety Practitioner

Co-ordination of infection prevention and control activities across the Trust and development of performance management framework (CSI).

Establish effective infection prevention and control audit tools.

Monitoring and correlation of risks (including updating of appropriate Trust risk registers) arising from business meetings, incident reporting and/or serious untoward incidents in relation to Infection prevention and control issues.

7.12 Specialist Paramedics Infection Prevention and Control:

Responsibility for co-ordinating the day to day infection prevention and control activities within their localities.

Responsibility for monitoring and reporting on infection prevention and control audits within their localities.

Ensure compliance with infection prevention and control legislation, policies and procedures.

Ensure infection prevention and control issues arising from all incident reporting are actioned and reported to the Head of Clinical Safety.

Liaise with Clinical Safety Practitioner on infection prevention and control risks.

Provision of advice and support in relation to infection prevention and control issues by liaison with Public Health England.

Assist with design and implementation of polices in relation to infection prevention, control and special infectious diseases.



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Manage any route cause analysis investigation involving NWAS staff in relation to HCAI i.e. MRSA / C Diff.

7.13 All Managers All Managers must ensure that infection prevention and control is treated as an integral part of their everyday role; as stated in the Management of Health and Safety at Work Regulations 1999. Their responsibilities should include:

They set a good example to all staff and act as a role model

Ensuring that current legislative and mandatory requirements are met.

Ensuring that the NWAS Infection Prevention and Control Policy and procedures is are made available to all staff and that it is maintained with necessary updates.

Compliance with the NWAS NHS Trust Infection Prevention and Control Policy and Procedures are monitored and where necessary, appropriate action is taken.

Adequate liaison and consultation is maintained with the Safety Representatives for staff.

Adequate liaison and consultation is maintained with the Clinical Safety Team.

Regular inspections and audits of the workplace are undertaken and any defects identified are managed appropriately.

Support is provided to ensure that continuous infection prevention and control audits can be undertaken and action plans implemented where required.

Information on infection prevention and control related matters is disseminated to all staff.

All reported incidents, including near misses in relation to infection prevention and control are sufficiently investigated with appropriate action taken to prevent reoccurrence.

7.14 All Employees The Health and Safety at Work Act 1974 also places duties upon Trust employees with regard to health, safety & welfare. Trust policies also require employees to take responsibility for their own and others safety. Therefore NWAS NHS Trust staff must:

Understand their responsibilities under this policy and related guidelines, to maintain and increase their knowledge of the subject relative to their role.



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Take reasonable care of their own safety and that of others who may be affected by their acts or omissions.

All staff should be up to date with their routine immunisations, e.g. tetanus, diphtheria, polio and MMR. The MMR vaccine is especially important in the context of the ability of staff to transmit measles or rubella infections to vulnerable groups. While healthcare workers may need MMR vaccination for their own benefit, they should also be immune to measles and rubella in order to assist in protecting patients. Satisfactory evidence of protection would include documentation of having received two doses of MMR or having had positive antibody tests for measles and rubella. (The Green Book 2013).

Not intentionally or recklessly interfere with or misuse any equipment provided in the interests of health, safety and welfare.

Wear the correct personal protective equipment when required and to immediately report any defects in such equipment.

Ensure they maintain good personal hygiene at all times and to ensure the cleanliness of equipment and vehicles they use, to reduce the transmission of Health Care Associated Infections, promoting patient and staff safety

Conform to NWAS NHS Trust policies and procedures relating to infection prevention and control.

Ensure that any equipment for service, maintenance or repair that has been in contact with or has potentially been in contact with body fluids is cleaned and where necessary disinfected, prior to being sent for service, maintenance or repair.

Report all incidents including near misses, involving themselves or a patient in their care as per the NWAS NHS Trust incident reporting procedure.

7.15 Occupational Health The Trust provides an Occupational Health service freely to all employees. They hold specific responsibilities for infection prevention and control as outlined in the associated procedures. Occupational Health services provide specialist advice to the Trust on infection, prevention and control within their scope of expertise. This service is available during normal working hours to provide advice and counselling in relation to infection prevention and control issues. Staff should be made aware of the infection risks associated with blood and body fluids, and sharps injuries as part of their induction and basic training.



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Further information on sharps and inoculation injury management can be found in the Infection Prevention and Control Procedures. The Trust has a free work based immunisation programme in place, which managed by occupational health services with appropriately qualified specialist (this does not includes those vaccines required for foreign travel unless on Trust business). These vaccines include. BCG vaccine is recommended for healthcare workers who may have close contact with infectious patients. It is particularly important to test and immunise staff working in maternity and paediatric departments and departments in which the patients are likely to be immunocompromised, e.g. transplant, oncology and HIV units. Hepatitis B vaccination is recommended for healthcare workers who may have direct contact with patients’ blood or blood-stained body fluids. This includes any staff who are at risk of injury from blood-contaminated sharp instruments, or of being deliberately injured or bitten by patients. Antibody titres for hepatitis B should be checked one to four months after the completion of a primary course of vaccine. Such information allows appropriate decisions to be made concerning post-exposure prophylaxis following known or suspected exposure to the virus. Influenza immunisation helps to prevent influenza in staff and may also reduce the transmission of influenza to vulnerable patients. Influenza vaccination is therefore recommended for healthcare workers directly involved in patient care, who should be offered influenza immunisation on an annual basis. Varicella vaccine is recommended for susceptible healthcare workers who have direct patient contact. Those with a definite history of chickenpox or herpes zoster can be considered protected. Healthcare workers with a negative or uncertain history of chickenpox or herpes zoster should be serologically tested and vaccine only offered to those without the varicella zoster antibody.

8.0 EDUCATION AND TRAINING The Trust will ensure that all relevant staff, contractors and other persons whose normal duties are directly or indirectly concerned with patient care receive suitable and sufficient training, information and supervision on the measures required to prevent and control risks of infection. All relevant staff, during their induction process will receive infection prevention and control awareness, and all operational staff will receive statutory and mandatory infection prevention and control training and refresher training on a regular basis. This is based on the Risk Management Training Needs Analysis which is regularly reviewed and implemented across the Trust. This will include as a minimum:



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Hand hygiene training and infection prevention and control awareness at induction for all employees

Infection prevention and control including hand hygiene being an integral component of all clinical courses.

Refresher training for all clinical staff in universal precautions, hand hygiene, vehicle and equipment cleaning and decontamination in the form of an e learning package and brief learning materials.

The safe use and disposal of sharps and actions to take in the event of an inoculation incident are included in; initial clinical training, e learning package and learning materials.

Infection Prevention and Control Policies and Procedures will be made available to staff in a variety of formats including electronic, web based, and hard copy on stations. They will be shown where to access this information as a follow up reference for use as necessary. A training needs analysis for all staff will ensure that relevant infection prevention and control training is regularly reviewed and implemented across the Trust. This will be reviewed and monitored as per the requirements of the Risk Management Training Procedure. Local managers will be expected to action where any deficiencies are identified. Training records of infection prevention and control instruction given will be kept to offer evidence to internal and external agencies (i.e. NHSLA, CQC) that all clinical staff are routinely educated in current infection prevention and control practice. Line managers are responsible for orientating their staff to the specific infection prevention and control procedures they may encounter, according to their operational responsibilities and within their occupational workplace.

9.0 ASSURANCE AND COMPLIANCE The Trust has conducted an assessment of the risks associated with healthcare associated infections and identified significant risks are detailed on the Trusts Assurance Framework. This framework provides structured assurances about where risks are being managed effectively and objectives are being delivered. Sources of assurances include policies and procedures, internal performance management, clinical safety indicators, minutes of relevant meetings, audit reports, and training records.

To ensure that the Trust policy and procedures are effective, constant monitoring will be undertaken both at organisational and local level. The Trust will measure against standards such as the NHSLA Risk Management Standards for Ambulance Trusts and the Health and Social Care Act 2008 criteria.



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The Care Quality Commission requires the Trust to sign a declaration to assess itself against core and developmental standards in relation to infection prevention and control. The aim of this declaration is to determine priorities, and implement plans, to achieve any progress necessary to meet these standards on an annual basis. New additional national targets for ambulance trusts have been introduced with an indicator assessment on infection prevention and control. This indicator is intended to test whether some of the basic structures and processes required under the code of practice are in place within the Trust. The Rationale behind this is that tackling healthcare associated infection cannot be left to clinical staff alone; senior management commitment, local infrastructure and systems are also vital. The code of practice for the prevention and control of health care associated infections was introduced under the Health and Social Care Act (2008). The code of practice will help NHS organisations to plan and implement how they can prevent and control healthcare associated infections. It sets out criteria by which managers of NHS organisations are to ensure that patients are cared for in a clean environment and where the risk of healthcare associated infections is kept as low as possible. The code of practice is available from the Department of Health website, publications and statistics section. The indicator is based on the response to six questions in relation to infection prevention and control; these include the organisation having an infection prevention and control audit programme, risk assessments on infection prevention and control issues, full cleaning and decontamination procedures, training, and Board accountability. The Trust will ensure that the systems and processes are in place to be able to answer these positively and give assurance to the Board. The organisation believes that learning can only take place if incidents are reported. It is imperative that the incident reporting system is used to allow for proactive as well as reactive risk management of healthcare associated infection. The Trust will ensure external reporting to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) Regulations 1995. The Medical Directorate will ensure the internal monitoring and learning from infection prevention and control reported incidents.

10.0 MONITORING The Chief Executive and the Board are responsible for monitoring the effectiveness of the Infection Prevention and Control Policy. The Board will receive an annual infection prevention and control report from the Director of Quality. The annual (Quality Assurance) Infection Prevention and Control Report will include:



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Detail progress against the annual infection prevention and control programme and action plan.

Demonstrate the effectiveness of the policy through the presentation of audit information and identified improvements in infection prevention and control standards.

Contain a summary of reported incidents reviewed by the infection prevention and control forum and resultant changes to practice.

A review of all inoculation incidents

Number of staff trained in infection prevention and control procedures through induction and refresher training.

Information publicly available via the Trusts website An infection control programme/ plan must be produced annually to maintain the Trusts compliance with local and national infection prevention and control policy and to achieve compliance with the Health and Social care act 2008 in respect of IPC issues. The implementation and progress will be monitored by the infection prevention and control forum and reported to the Clinical Governance Management Group. The progress of the IPC programme is reported as part of the Health act assessment plan and the IPC action plan.

This policy and associated infection prevention and control procedures will be monitored for their effectiveness by the Head of Clinical Safety to ensure that they continue to reflect best practice and remain consistent with the Trusts clinical protocols and other relevant policies. Responsibilities of staff in relation to managing the risks associated with both infection prevention and control and inoculation incidents will be monitored on an annual basis through the regular review of incidents and the development of records. Monitoring will also take place through the independent audits undertaken by the Advanced Paramedics and Specialist Paramedics for Infection Prevention and Control, and through the Service Delivery audit programme. These will be reported at least four times per year. The Trust is monitored externally by the NHSLA, and the Care Quality Commission. In order to achieve compliance the Trust is required to provide relevant and sufficient evidence in meeting these standards. 10.1 Inoculation incidents In order to meet levels 1 – 3 of the NHSLA standards with regard to inoculation incidents the Trust has approved documentation which describes the process for managing inoculation incidents. All staff have a duty to report any inoculation incident as part of the incident reporting policy and the Trust ‘Sharps Management’ Procedure. The Trust’s Occupational Health Procedure and Infection Prevention Control procedures also details the process for the immediate management (including prophylaxis) of an inoculation injury. All relevant staff



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are trained in these policies as part of their induction and infection prevention and control refresher training. Incidents are monitored by the Specialist Paramedics for Infection Prevention and Control who report these at least twice per year to the Infection Prevention and Control Forum. Any deficiencies or issues are actioned accordingly as part of the infection prevention and control action plan. Any risks identified are highlighted and added to the directorate and/or Corporate Risk Register. 10.2 Infection Prevention and Control Levels 1 – 3 of the NHSLA standard for infection prevention and control require the Trust to have approved documentation, implementation and processes in place which describes the processes for managing the risks associated with infection prevention and control. The Trusts Infection Prevention and Control policy and its associated procedures details the requirements set out in the standards, these include information on staff training, staff duties, incident reporting, information for staff and patients and infection prevention and control monitoring. A clinical safety report submitted at least twice a year to the Clinical Governance Management Group contains the infection prevention and control assurance framework and provides the assurance to the group on all infection prevention and control matters with a detailed status position, action plan and annual audit programme. Any risks are identified, actioned where appropriate and added to the Risk Register as necessary. The Process for monitoring the effectiveness of the above standards is through the following actions:

Completion of Incident report form and investigation by local managers.

Incident reporting statistics and trend analysis monitoring.

‘Lessons learnt’ and action plans.

Infection Prevention and Control Forum monitor incidents and make any recommendations.

Trust Incident learning Forum monitor and make any recommendations.

Training records.

Annual audit plan and action plan monitoring.

11.0 AUDIT The Trust should be active in ensuring that the appropriate policies and procedures required ensuring a safe environment for patients, staff and visitors are in place and implemented. To this end infection prevention and control environmental audits should be performed throughout the Trust. All Trust ambulance station premises and ambulance vehicles will be subjected to regular audit and inspection as detailed in this Infection prevention and control policy and in line with the Health and Social Care Act 2008, and the DOH Essential Steps, safe, clean care.



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The Trust’s Infection Prevention and Control Audit tool has been developed to look at key performance (Clinical Safety) indicators including:

The general hygiene of ambulance stations, cooking/washing facilities, and food storage.

The storage and disposal of clinical waste and sharps.

The storage of used linen.

The decontamination and cleanliness of ambulance vehicles and medical devices

The knowledge and competency of staff on IPC issues. These audits will be undertaken for stations and vehicles spread over the year period. Audits by the independent Specialist Paramedics will be at least on an annual basis and reported Quarterly. Service Delivery audits and SPIPC audit results will report to the Quality Business Group and to the Trust Board on a quarterly basis. This will ensure that any non-compliance is identified and actioned appropriately and quickly. Service Delivery Audit reports should be completed on line as part of the web based tool for monitoring performance. Line managers will be responsible for rectifying any faults identified and action plans, summaries and audit reports should be tabled and discussed at the area clinical quality improvement forums. Serious or persistent problems should be identified to and addressed by Service Delivery and monitored through the Clinical Safety Team through the Infection Prevention and Control Forum. These audit results will be reported as part of the Clinical Safety Indicator report to the Trust Board via the Quality Committee. Station and vehicle cleanliness audits should be undertaken by PES and Patient Transport Service staff on a daily and weekly basis as part of the Service Delivery performance monitoring. The Service Delivery managers will input this data onto the web based reporting tool and monitor any actions that are required. Audits for vehicles that have been deep cleaned should also be undertaken. All audit results and action plans should be monitored through the Clinical Quality Improvement Forums, QBG, and Quality Committee. Random mini audits of vehicles and stations may also be undertaken by senior managers across the Trust. These mini audits will be undertaken by managers from any directorate who may be on Trust business on stations or at other NHS premises. Audit results will be forwarded to the Clinical Safety Team for further review, auditing, and appropriate action. Further audits may be requested by the Clinical Governance Management Group or Quality Committee, as appropriate. This may include sharps injuries, Hand Hygiene audits, work acquired infections, work related injuries etc. as part of Key performance indicator work.

12.0 INFORMATION SHARING When transporting patients from one healthcare setting to another NWAS will ensure that information is passed between the two settings including the Patients infection status and



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that any infection prevention and control risks or issues have been identified and actioned appropriately. Information regarding the risks and nature of HCAI’s that are relevant to the patient’s own care must be communicated. Infection Prevention and Control information is shared between NWAS and its occupational health providers in order to protect staff and patients from risks. Infection Prevention and Control information is shared with Public Health England; Commissioners of NWAS services; Enforcement Agencies and other NHS partner organisations in order to comply with legal requirements or reduce the potential risks associated with the transmission of Healthcare Associated Infection information HCAI’s (i.e. MRSA, C Diff etc.). Infection Prevention and Control information will be made available for Patients and the Public. These will include posters, leaflets and Internet information on NWAS Infection Prevention and Control Policies and Procedures, and the Trusts arrangements for reducing HCAI’s.

13.0 EQUALITY AND DIVERSITY This policy embraces diversity, dignity and inclusion in line with emerging Human Rights guidance. We recognise, acknowledge, and value differences across all people and their backgrounds. We will treat everyone with courtesy and consideration and ensure that no one is belittled, excluded, or disadvantaged in any way, shape, or form. The Trust supports Equality and Diversity and an Equality Impact Assessment of this policy has been undertaken. Results of this Assessment can be found at Appendix 1.

14.0 DOCUMENT DEVLOPMENT AND REVIEW The Infection Prevention and Control Policy and associated procedures have been developed in consultation with the Infection prevention and control Forum, Clinical Governance Management Group and Public Health England. The Trust is also a member of the National Ambulance Infection Prevention and Control Group. The DIPC is responsible for ensuring that the policy is reviewed on a regular basis. This will ensure that it remains current, complying with legislation, national guidance and therefore reflecting ‘best practice’.

15.0 RELATED POLICIES AND PROCEDURES The Trust has developed Infection Prevention and Control Procedures so that staff understand their personal responsibilities for controlling and preventing infection. The



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procedure document provides information relating to the mechanisms involved in the spread of infection; personal hygiene; personal protective equipment; cleaning of vehicles and equipment and other issues such as the management of healthcare waste. The Trust reviews infection prevention and control procedures annually to ensure that they continue to reflect best practice. The Trust has various policies and procedures that support this policy: Infection Prevention and Control Procedures Communicable Diseases Policy Waste Management Procedures Latex Sensitivity Policy Linen Management Policy Incident Reporting and Investigation Policy Risk Management Strategy and Policy HAZMAT plan including decontamination Pandemic Flu Policy Health and Safety Policy Control of Substances Hazardous to Health (COSHH) Assessments Hand washing, mop posters, information posters and leaflets Vehicle and station cleaning schedules and audit documentation

Other policies will continue to be produced and implemented by the Trust which supports the prevention and control of Infection.

16.0 REFERENCES

Health and Social Care Act 2001 (c.15) London: HMSO

NHS Constitution for England, available at

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume

nts/digitalasset/dh_113645.pdf

17.0 IMPLEMENTATION AND MONITORING

IMPLEMENTATION AND MONITORING PLAN

Intended Audience All NWAS staff

Dissemination Available to all staff on the Trust intranet, hard copies on Trust premises, and to the public on the NWAS website.

Communications Revised policy and procedures to be announced in ‘Clear Vision’ and a link provided to the document.

Training Training to be carried out as outlined in Section 8 of this policy in line with the Risk Management Training Needs Analysis.

Monitoring To ensure adherence to this policy the Head of Clinical Safety will ensure that the annual programme of audits continues to take

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf



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place. The monitoring of audits and assurance checks to be carried out by the IPC Forum/IPC Paramedics on receipt of reports from service delivery and also on a regular basis. This will be at least four times per year.

APPENDIX 1



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Equality Impact Assessment Report

Name of Policy, Service or Function Infection Prevention and Control Policy

Equality Impact Assessment carried out by Deborah Bullock, Head of Clinical Safety Specialist Paramedics Infection Prevention and Control

Date of Equality Impact Assessment 17/2/2014

Step 1: Description and Aims of Policy, Service or Function Overall aims

To provide information, instruction and training to the workforce in order that staff are aware of their duties and responsibilities under current regulations.

To disseminate information about Infection prevention and control issues to relevant staff

To safeguard patients and staff

Produce Trust guidance on the management of IPC including appropriate PPE

Reduce risk, promote a safer working environment and promote best practice

Assist the Trust in complying with the Clinical Governance and Health and Safety legislation

Encouraging staff at all levels to adopt responsibility for their own safety and that of others who may be affected by their acts or omissions.

Ensuring that relevant staff are aware of how cross infection occurs and the steps they, as an individual must take to adequately control such risks.

Ensuring that relevant staff at all levels receive training to the best current information regarding infection prevention and control, enabling them to be fully conversant with the risk to themselves and where appropriate, to the patients in their care.

Providing relevant staff with clear work procedures and safe systems of work wherever applicable.



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Ensuring that relevant staff have access to any personal protective equipment to help reduce the risk of infection and that they are trained to correctly use, clean, store and dispose of such equipment.

Ensuring staff are aware of techniques to ensure good personal hygiene.

Ensuring relevant staff are aware of techniques required to adequately clean and where necessary disinfect equipment and vehicles.

Key elements of policy, service, process To disseminate information about IPC to relevant staff Reduce risk, promote a safer working environment and promote best practice Who does the policy, service or function affect? Healthcare staff, both internal and external Patients Support Staff How do you intend to implement the policy or service change (if applicable?) To be approved by the Trust Board Available on Trust Intranet/internet Copy available on all sites Disseminated to all Teams and appropriate groups Step 2: Data Gathering Summary of data available and considered

Health & Safety at Work Act

Health & Safety Executive Guidance

The Health and Social Care Act 2008: Code of Practice for the NHS on the Prevention and Control of Health Care Associated Infections and related guidance (Department of Health; January 2009)

Ambulance Guidelines; reducing infection through effective practice in the pre-hospital environment (Department of Health; June 2008)

National Patient Safety Agency which takes account of current legislation and Government policy and guidance

The National Specifications for Cleanliness in the NHS: a framework for setting and performance measuring performance outcomes in ambulance trusts (National Patient Safety Agency: 2008)

Uniforms and Work wear: an evidence base for developing local policy (Department of Health: March 2010)



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Managing Healthcare Associated Infection and Control of Serious Communicable Diseases in Ambulance Services (Ambulance Service Association; November 2005).

NHSLA risk management standards for Ambulance Trusts.

Department of Health’s Essential Steps to Safe, Clean Care.

NICE guidance on HCAI 2012

Waste management regulations 2011

EU sharps regulations 2013

Outcomes of data analysis

Equality Group

Evidence of Impact

Gender

No impact

Race/Ethnicity

Impact on persons who do not have English as their first language

Disability May impact on persons with visual impairment

Sexual Orientation

No impact

Religion or belief

No Impact

Age

No Impact

General (Human Rights)

No Impact

Step 3: Consultation Summary of consultation methods



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Consulted with

Former Risk Management Sub-committee and business groups

Former Health, Safety & Security Sub-Committee and business groups

Clinical Governance Management Group

Infection Prevention and Control Forum

Occupational Health

Medical Directorate team members

Health protection Agency

Quality Committee

Executive Management Team

Outcomes of consultation

Equality Group

Evidence of Impact

Gender

No Impact

Race/Ethnicity

May be required in alternative language formats

Disability May impact on the visually impaired

Sexual Orientation

No Impact

Religion or belief

No Impact

Age

No Impact

General (Human Rights)

No Impact



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Date of Approval: Status: Draft

Date of Issue: Date of Review April 2014

Step 4 & 5: Impact Grid

Relevant Equality Area

Areas of impact identified Is the impact

positive or negative?

Key issues for action [Will form basis of action

plan]

Gender None Positive improvement

on equality

Race/Ethnicity May impact on persons who do not have English as their first language Positive improvement

on equality

Should be available in alternative language

formats Disability Impacts on visually impaired, persons with learning difficulties and

medical learning needs

Available in other formats where requested

Accessible language to be used

Sexual Orientation None Positive improvement

on equality

Religion or belief None Positive improvement

on equality

Age None Positive improvement

on equality

General (Human Rights) None Positive improvement

on equality



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Step 6: Action Plan

Name of Policy or Service: Incident Reporting and Investigation Policy

Issue identified and equalities group or

communities affected

Action to be taken By When Who By Expected outcome Progress

Language barrier If deemed necessary the Trust will provide this policy in an alternative format.

As requested

Medical Directorate

Alternative language formats

None

disability Produce large format in accordance with the principles of the RNIB clear print guidelines

As requested

Medical Directorate

Large print version produced

none

Summary of decisions and recommendations Production of large print version in accordance with RNIB clear print guidelines on request To be made available in alternative language formats on request Production in alternative formats for persons with learning difficulties on request

Step 7 Monitoring arrangements The implementation of the procedure will be monitored over the next 12 months, in the following respects:

Individual EIA’s will be monitored from a quality perspective

Key action plans will be monitored Step 8 Date of next Equality Impact Assessment At next review of policy



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Documents

Infection Prevention and Control Policy - Home of NWAS · PDF file11.0 Audit 20 12.0 Information ... Infection Control Action plan in place engages with the ... Infection Prevention