NHS Fife acknowledges and agrees with the importance of regular and timely review of policy/procedure statements and aims to review policies within the timescales set out.
New policies/procedures will be subject to a review date of no more than 1 year from the date of first issue.
Reviewed policies/procedures will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.
If a policy/procedure is past its review date then the content will remain extant until such time as the policy/procedure review is complete and the new version published, or there are national policy or legislative changes.
The purpose of this overarching policy is to ensure that responsability for prevention and control of Healthcare Associated Infection (HAI) is embedded at all levels of the organisation, and to clarify the responsabilities as laid down in national directives for prevention and control of infection, from the Chief Executive and NHS Board through to individual practitioners
It describes the processes to prevent healthcare associated infections that will be implemented within NHS Fife to ensure the application of the highest standards in accordance with the requirements of NHS Healthcare Improvement Scotland (HIS), the strategic direction laid down in the Scottish Government Health & Social Care Directorate (SGHSCD) HAI Taskforce Delivery Plan (2011) and Healthcare Associated Infection and Antimicrobial Resistance (AMR) Policy Requirements DL (2015) 19.
It is supported by the Standard Operating Procedures (SOPs) laid down in the NHS Fife Infection Prevention and Control Manual (the Manual) and the NHSScotland National Infection Prevention and Control Manual 2015.
This policy applies to all staff within all the component parts of NHS Fife. It also applies to private and independent contractors working on NHS Fife premises, including GPs in community hospitals, locum and agency staff, and volunteers. It is offered as best practice guidance for independent contractors on their own premises.
3.1. NHS Fife Board
Responsibilities of the Board are laid down in Healthcare Associated Infection (HAI) Standards February 2015.
3.1.1 The Board must:
Ensure the organisation demonstrates leadership and commitment to infection prevention and control to ensure a culture of continuous quality improvement throughout the organisation. Ensure executive leaders and their teams have a working knowledge, appropriate to their role in the organisation, of the infection prevention and control policies and procedures as well as the national and local priorities that impact on care within the organisation. (Standard 1 Statement). This includes all the elements set out in Appendix 1.
3.1.2. These responsibilities are discharged through the establishment of the following posts and structures:
- Director of Public Health
- Public Health Consultant in Communicable Disease and Environmental Health
- Executive Lead for Infection Control
- Executive Lead for Decontamination
- Infection Control Committee Structure
3.2. Board Chief Executive
Has overall responsibility for the provision of infection control within NHS Fife.
The responsibilities of the Chief Executive with respect to infection control are laid down in HDL 2005 (8) and are set out in full in Appendix 2:
3.3. Executive Lead for Infection Control
Reports to the NHS Fife Chief Executive and is responsible for ensuring the delivery of the Board’s key responsibilities relating to prevention and control of infection and HAI.
The Executive Lead’s responsibilities are set out in full in Appendix 3.
3.4. Infection Control Manager (ICM)
Appointment to this post was made in response to HDL (2001)10 with the role and responsibility of the ICM being further defined in HDL 2005 (8).
The ICMs responsibilities are set out in full in Appendix 4.
3.5. Infection Control Doctors (ICD)
The role and function of the Infection Control Doctors (ICD) is to provide strategic leadership in conjunction with the ICM and NCIPC for infection prevention and control to NHS Fife
The ICD’s responsibilities are set out in full in Appendix 5.
3.6. Nurse Consultant: Infection Control (NCIC)
The NCIC provides professional and clinical leadership within and through the Infection Prevention and Control Team (IPCT).
The NCIC’s responsibilities are set out in full in Appendix 6.
3.7. Infection Prevention & Control Team (IPCT)
The IPCT provides expert reactive and proactive advice and information to all staff within all the component parts of NHS Fife, private and independent contractors working on NHS Fife premises, including GPs in community hospitals, locum and agency staff, and volunteers. Full responsibilities are set out in Appendix 7.
3.8. Infection Control Committee (ICC)
The Terms of Reference (TOR) for the ICC set the parameters of their responsibilities, full details of which are set out in Appendix 8.
3.9. Directors, General Managers and Line Managers are responsible for ensuring they have a comprehensive understanding of their own remit within this policy and associated procedures or guidance laid down in the Infection Prevention and Control Manual. Their explicit responsibilities are set out in Appendix 9.
3.9.1. The role of the Charge Nurses/Ward Leaders in infection control is further defined within HDL (2005)7 and includes the following: -
- Must undertake the ‘Cleanliness Champions’ educational programme or equivalent.
- Should ensure that all nurses have Personal Development Plans (PDP) that contain specific objectives for continuing professional development in HAI.
- Are expected to set sensible limits on visiting, ensuring that visitors don’t sit on beds and minimising the risk to patients.
- Are responsible for ensuring that any local or national infection control guidance is implemented within their areas.
- Should have the authority to require local cleaning services to act timely on any problems identified.
- Charge nurses should be involved in auditing compliance with infection control policies and cleaning schedules within their areas.
3.10. All members of staff
Staff have a responsibility to demonstrate an acceptable level of competence in the workplace relating to control of HAI.
- Ensure they have received appropriate infection prevention and control training including hand hygiene instruction in the last twelve months and fully adhere to Hand Hygiene SOPs.
- Never knowingly place a patient, member of staff or NHS Fife visitor at risk from an infection.
- Work to the infection control and related standards set out in the NHS Fife’s infection control policy and Manual.
- Adopt national evidence based guidance in order to ensure patients are treated according to best practice.
- Challenge poor infection prevention and control practice and seek support from the IPCT as required.
- Communicate proactively and reactively with the IPCT ensuring clear lines of communication.
- Obtain advice from the IPCT or Occupational Health if they are concerned over their own risks.
4. OPERATIONAL SYSTEM
The aim of this policy statement is to ensure that NHS Fife provides a management process and framework under which all infection control activities will operate.
This policy is underpinned by the Infection Prevention and Control Manual, which details standard operating procedures and guidance for all aspects of infection prevention and control and is an integral part of this policy statement. All staff must be made aware of this document. It is also supported by the Prevention and Control of Infection Annual Work Programme, and the NHS Fife Prevention and Control of Infection Annual Report.
4.1. The following functional arrangements for infection control are defined within the Health Improvement Scotland (HIS) HAI Standards 2015, namely
- The Prevention and Control of Infection Annual Work Programme
- The Prevention and Control of Infection Annual Report
- The Infection Prevention and Control Manual
- The full operational system for these issues is set out in Appendix 10.
4.2. The Infection Prevention and Control Manual covers:
- Staff health
- Standard infection control precautions and Transmission Based Precautions
- Outbreak Management
- Norovirus outbreak management
- Management of patients with loose stools
- Creutzfeldt-Jacob Disease
- Clostridium difficile
- Carbapenemase producing Enterobacteriacea (CPE)
Manual sections are reviewed on a rolling programme (and more frequently if national guidance changes) and the programme of reviews for the forthcoming year will be documented in the Prevention and Control of Infection Annual Work Programme for the year.
5. RISK MANAGEMENT
5.1. The risk to staff, patients and visitors will be managed by the application of the procedures laid down in the NHS Fife Infection Prevention and Control Manual
5.2. Risks will be documented in the Infection Prevention and Control Risk Register and reviewed bimonthly by the ICC.
5.3. Governance arrangements are laid down in the NHS Fife Prevention and Control of Infection Implementation Framework 2015-17 and risks will be escalated in line with the pathways laid down in that document.
6. RELATED DOCUMENTS
NHS Fife Infection Prevention and Control Manual
NHS Fife Prevention and Control of Infection Implementation Framework 2015-2017
SGHSCD HAI Taskforce Delivery Plan (2011)
NHSScotland National Cleaning Services Specification (2016)
National Infection Prevention and Control Manual (2015)
SHFN 30: Part A & Part B (2014)
HDL (2001)10 Decontamination of Medical Devices
HDL (2005) 7 Infection Control and Cleaning: Nursing Issues
HDL (2005) 8 Infection Control: Organisational Issues
Health and Safety at Work Act 1974
Management of Health and Safety of Work (MHSW) Regulations, 1999
The Public Health (Control of Disease) Act 1984;
The Public Health (Infectious Diseases) Regulations 1988;
Personal Protective Equipment at Work Regulations 1992;
Control of Substances Hazardous to Health Regulations 2002 (including amendments);
Infection Control in Adult Care Homes: Final Standards, 2005;
The Food Safety Act 2009;
The Food Safety Regulations – Regulation (EC) No 852/2004 in the Hygiene of Food
stuffs and The Food Hygiene (Scotland) Regulation 2006.
- GPI8 - Appendix 1 - Responsibilities of the Health Board
- GPI8 - Appendix 10 - Documents underpinning and supporting the Infection Control policy
- GPI8 - Appendix 2 - Responsibilities of the Board Chief Executive
- GPI8 - Appendix 3 - Responsibilities of the Executive Lead for HAI Infection Control
- GPI8 - Appendix 4 - Responsibilities of the ICM
- GPI8 - Appendix 5 - Responsibilities of the ICDs
- GPI8 - Appendix 6 - Responsibilities of the NCIC
- GPI8 - Appendix 7 - Responsibilities of the ICT
- GPI8 - Appendix 8 - Responsibilities of the IC
- GPI8 - Appendix 9 - Responsibilities of Directors, General Managers and Line Managers
- GPI8 - Infection Control - EQIA