INSERT PRACTICE NAME HERE
OCCG IPC Core Policy 1;
Infection Prevention Policy and Programme
Contents
- Introduction
- Statement from Practice Manager/Lead Doctor
- Accountability and Responsibilities
- Practice manager/Lead Doctor
- Infection prevention lead
- Decontamination lead
- Individuals
- Antimicrobial prescribing
- Attached staff
- Occupational health
4Public Health England Centres
5OCCG infection control team
6Policies
7Audit
8Training and development
9References
10Appendix – example IPC Programme
Date issued: August 2016
Date for review: August 2019
3 yearly or earlier if new guidance published
OCCG Core Policy 1
Infection Prevention and Control Policy and Programme
- Introduction
- 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.
1.2This policy applies to all members of (name of practice). All staff, both clinical and non-clinicalare 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.
1.3The 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.
1.4This 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.
1.5An annual programme of infection prevention & control will be written and followed by the practice.
2Statement by the Practice manager/lead doctor
2.1Healthcare 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.
2.2Prevention 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.
2.3The 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
3Responsibilities
3.1Practice 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
3.2Infection 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
3.3Designated 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
3.4Individuals
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.
3.5Antimicrobial 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.
- 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.
3.6Attached 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.
3.7Staff 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.
4Public 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.
5OCCG Infection Control advice
The OCCG infection control team is based at Jubilee House.
- Lead for Infection Prevention and Control 01865 336856
6Policies
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.
7Audit
An annual audit of infection control should take place. This can be a self-assessment or an invited team.
8Training and Development
8.1The 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.
8.2The 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
8.3Infection control will be included in new staff induction training.
9References
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.
9.2 OCCG Prescribing Guidelines for the use of Antimicrobial Agents in Primary Care
9.3 DoH (2015)UK 5 year antimicrobial resistance strategy
9.4 TARGET toolkit
9.5 Department of Health (2003), Winning Ways, Working together to reduce Healthcare Associated Infection in England.
9.6 NICE (2012) Healthcare associated infections; prevention and control in primary and community care
Infection control programme / 1INSERT 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 frequency / OutcomeThere are systems to manage and monitor the prevention and control of infection. /
- There is an infection prevention programme in place
- An annual audit will take place
- There is a nominated lead for infection prevention and control.
- There are the appropriate policesprocedures and guidance in place to provide a clean, safe environment
- An annual statement will be presented to the practice (date)
PM/ Practice IPC lead
Practice IPC lead / At practice governance meeting
Annual review
Annually (date- after April each year)
There is a training programme in place /
- 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
- All non-clinical staff will have infection prevention training every two years
The practice will provide a safe, clean environment that prevents and controls infection. /
- 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
Decontamination lead / Minimum annual audit; bi-annually preferable
There is a system in place that keeps service users informed of the practice approach to infection prevention and control /
- 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)
The practice will ensure that information is shared between healthcare providers on any infection that a service users may have (MRSA- C.diffetc) /
- Ensuring confidentiality, any letters or referrals to other organisations will have relevant infection information included.
Staff will be protected from exposure to blood borne viruses through immunisation, safe management of exposure and safe use and disposal of sharps and /
- 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.
- This above will be checked as part of the infection control audit cycle
There is a local policy in place for antimicrobial prescribing and a system of audit is in place. /
- 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.
Waste is managed and complies with the National Waste Guidance /
- All waste is appropriately labelled
- Staff are trained to comply with waste systems
- A waste audit carried out
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. /
- Development of risk register for practice
- Replacement programme for damaged equipment
Infection control programme / 1