Infection Prevention And Control Policy

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Policy DirectiveInfection Prevention and Control PolicySummary This Policy Directive outlines practices required to minimise the risk of patients, visitors,volunteers and health workers (HWs) acquiring a healthcare associated infection, multiresistant organism colonisation or communicable disease.Document type Policy DirectiveDocument number PD2017 013Publication date 07 June 2017Author branch Clinical Excellence CommissionBranch contact (02) 9269 5603Replaces PD2007 036;PD2010 058;PD2009 030;PD2007 084;PD2005 414Review date 07 June 2022Policy manual Not applicableFile number D17/2444Status ActiveFunctional group Clinical/Patient Services - Medical Treatment, Nursing and MidwiferyPersonnel/Workforce - Industrial and Employee RelationsPopulation Health - Communicable Diseases, Infection ControlApplies to Affiliated Health Organisations, Board Governed Statutory Health Corporations, CancerInstitute, Chief Executive Governed Statutory Health Corporations, Community HealthCentres, Dental Schools and Clinics, Environmental Health Officers of Local Councils,Government Medical Officers, Local Health Districts, Ministry of Health, NSW AmbulanceService, NSW Health Pathology, Private Hospitals and day Procedure Centres, PublicHealth System Support Division, Public Health Units, Public Hospitals, Specialty NetworkGoverned Statutory Health CorporationsDistributed to Divisions of General Practice, Environmental Health Officers of Local Councils,Government Medical Officers, Health Associations Unions, Ministry of Health, NSWAmbulance Service, Private Hospitals and Day Procedure Centres, Public Health System,Tertiary Education InstitutesAudience All staff from NSW Health Organisations; Affiliated Health Organisations; NSW Ministry ofHealthSecretary, NSW HealthThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.

POLICY STATEMENTINFECTION PREVENTION AND CONTROL POLICYPURPOSEThe primary purpose of the NSW Health Infection Prevention and Control Policy is toprovide leadership to NSW Health Organisations (including Affiliated HealthOrganisations) on how to effectively prevent, manage and control healthcare associatedinfections (HAIs), in order to minimise the adverse health impacts on patients treatedwithin health care and reduce the burden of HAIs.MANDATORY REQUIREMENTSLocal infection prevention and control documents are to align with the principles outlinedin this Policy Directive and are consistent with the principles and practices outlinedwithin the NSW Infection Prevention and Control Practice Handbook.(this will bereferred to as ‘Handbook’)IMPLEMENTATIONNSW Public Health Organisations (PHOs) provide the mandatory requirements and thegovernance structure for the implementation of this Policy Directive to reduce the risk ofhealthcare associated infections (HAIs).Clinical Excellence Commission Provides tools to support the implementation, monitoring and evaluation of thispolicy Maintains currency of the NSW Infection Prevention and Control PracticeHandbook.Health Education and Training Institute Provides educational resources to support the implementation and compliance withthis policy.Chief Executive of Local Health District and Specialty Health Network Assigns leadership responsibility, personnel and resources to implement andcomply with this policy.Directors of Clinical Governance Ensure that this policy is communicated to all managers and health workers Ensure local infection prevention and control programs and systems are in place Monitor and provide regular reports on the progress and outcomes of the infectionprevention and control program Monitor, evaluate and address issues with compliance with this policy.Clinical leaders and senior managers Implement and evaluate local infection prevention and control systems.PD2017 013Issue date: June-2017Page 1 of 2

POLICY STATEMENTInfection prevention and control professionals Provide leadership in infection prevention and control surveillance and reporting Provide advice on infection prevention and control within their health organisation Provide leadership in the management of HAIs or other transmission risks and in thecommunication of these risks to health workers, patients, volunteers, carers andvisitors.Health Workers Comply with the requirements of this policy.REVISION HISTORYVersionApproved byAmendment notesJune 2017(PD2017 013)Deputy Secretary,Governance,Workforce andCorporateUpdated and amalgamation of the following policies: PD2005 414 Infection Control Program Quality Monitoring PD2007 036 Infection Control Policy PD2007 084 Infection Control Policy Prevention andManagement of Multi-Resistant Organism PD2009 030 Infection Control Policy – Animals as Patientsin Health Organisations PD2010 058 Hand Hygiene Policy.ATTACHMENTS1. Infection Prevention and Control Policy: Procedures.PD2017 013Issue date: June-2017Page 2 of 2

Infection Prevention and Control PolicyPROCEDURESIssue date: June-2017PD2017 013

Infection Prevention and Control PolicyPROCEDURESCONTENTS1BACKGROUND . 11.11.21.31.423About this document . 1Scope . 1Key Definitions . 1Legislative requirements . 4THE RISK OF HEALTHCARE ASSOCIATED INFECTIONS . 5CLINICAL GOVERNANCE REQUIREMENTS . 53.13.2National Accreditation Standards . 5Infection prevention and control committees . 54. RISK MANAGEMENT . 54.14.25RISK IDENTIFICATION REQUIREMENTS . 65.15.26Incident management . 6Provision of education . 6Risk assessment of the patient . 6Risk rating of the clinical area (functional area) . 7RISK MITIGATION REQUIREMENTS . 76.16.26.3Standard precautions . 7Hand hygiene . 86.2.1 Patient and visitor hand hygiene . 9Personal protective equipment . 96.3.1 Gloves . 96.3.2 Masks . 106.3.3 Eyewear and Facial Protection . 116.3.4 Gowns and Aprons . 116.3.5 Aseptic technique . 116.3.6 Safe handling of used linen . 126.3.7 Respiratory hygiene and cough etiquette . 126.3.8 Safe use and disposal of sharps . 126.3.9 Environmental cleaning. 127REPROCESSING OF RE-USABLE MEDICAL DEVICES (RMDS) . 138SINGLE USE AND SINGLE PATIENT USE DEVICES . 139SHARED PATIENT CARE EQUIPMENT . 1410 PROCUREMENT OF NEW DEVICES OR EQUIPMENT . 1411 SAFE INJECTION AND MULTI-DOSE VIALS . 1412 SAFE HANDLING AND TRANSPORT OF PATIENT SPECIMENS . 1513 TRANSMISSION BASED PRECAUTIONS . 1514 BED MANAGEMENT AND PATIENT FLOW . 1615 ANTIMICROBIAL STEWARDSHIP . 1616 MANAGEMENT OF HEALTH WORKERS WITH SYMPTOMATIC ILLNESS . 1716.1 Occupational assessment, screening and vaccination . 1717 ADDITIONAL CONTROLS . 1717.1 Animals . 17PD2017 013Issue date: June-2017Contents page

Infection Prevention and Control PolicyPROCEDURES17.2 Construction, renovation and refurbishment . 1818 COMMUNICATION REQUIREMENTS . 1818.1 Clinical documentation and communication . 1818.2 Communication with patients, family and carers . 1919 SURVEILLANCE REQUIREMENTS. 1920 OUTBREAK MANAGEMENT REQUIREMENTS. 1921 LOOKBACK . 2022 REFERENCES. 2323 LIST OF ATTACHMENTS . 2424.124.224.324.424.5ATTACHMENT 1 – POLICY IMPLEMENTATION CHECKLIST . 25ATTACHMENT 2 – SUMMARY OF STANDARD PRECAUTIONS. 27ATTACHMENT 3 – SUMMARY OF CONTACT PRECAUTIONS . 28ATTACHMENT 4 – SUMMARY OF DROPLET PRECAUTIONS . 29ATTACHMENT 5 – SUMMARY OF AIRBORNE PRECAUTIONS. 30PD2017 013Issue date: June-2017Contents page

Infection Prevention and Control PolicyPROCEDURES1BACKGROUND1.1 About this documentThis Policy Directive outlines the mandatory infection prevention and control requirementsfor NSW Public Health Organisations. This policy must be read in conjunction with theNSW Infection and Prevention Control Practice Handbook. [1]1.2 ScopeThis Policy Directive must be implemented within NSW Health Organisations.The scope of this policy includes: Requirements for the infection prevention and control program Strategies for the prevention and management of HAI including those caused bymulti drug resistant organisms (MROs) and communicable diseases Reprocessing of reusable medical devices Direction on governance and quality monitoring (surveillance) Infection prevention and control incidents and risk Standard and transmission based precautions Outbreaks of transmissible infections and communicable diseases Handling of animals as patients.The handling and management of body substances and cytotoxic waste i.e. bodysubstances and any discarded materials containing unmetabolised or residual cytotoxicmedication is outside the scope of this policy. Guidance on this is provided in NSW HealthWaste Management Guidelines for Health Care Facilities PD2005 132 and High RiskMedicines Management Policy PD2015 029.11.3 Key DefinitionsAirborne precautionA transmission-based precaution used to interrupt transmission from patientsknown or suspected to be infected with agents transmitted person-to-person bythe airborne route [2].Alcohol basedhandrub (ABHR)An alcohol-containing preparation (gel, foam or liquid) designed for reducing thenumber of viable microorganisms on dry, unsoiled hands.Alert/De-AlertEnabling of an electronic communication warning ‘flag’ that indicates MROcolonisation or infection in a patient’s clinical records.De-Alert is the inactivation of the electronic infection control Alert (flag).AntimicrobialA chemical substance , usually a medicine, that inhibits or destroys bacteria,viruses fungi or protozoa [1] [3]1Section 4: NSW Infection prevention and Control Practice Handbook, Principles for NSW public healthorganisations [1]PD2017 013Issue date: June-2017Page 1 of 30

Infection Prevention and Control PolicyPROCEDURESAntimicrobialstewardshipAn ongoing program within a health organisation for judicious antimicrobial use inorder to improve patient outcomes, ensure cost-effective therapy and reduceadverse sequelae of antimicrobial use, including antimicrobial resistance [4].Aseptic techniqueAseptic technique consists of a set of practices aimed at minimisingcontamination and is particularly used to protect the patient from infection duringclinical procedures. The five essential principles of aseptic technique aresequencing, environmental control, hand hygiene, maintenance of aseptic fieldsand personal protective equipment (PPE). While the principles of aseptictechnique remain constant for all procedures, the level of practice will changedepending upon a standard risk assessment [2].Body substanceBody substance is used rather than body fluid to emphasise the need forprecautions to prevent contact with solid tissue and faeces as well as blood(including dried blood) and body fluids. This does not include intact skin, hair andsweat.CleaningThe removal of visible soil (e.g. inorganic and organic material) from objects andsurfaces and is normally accomplished manually or mechanically using water withdetergents or enzymatic products [5]Clinical governanceA clearly defined framework of accountability at all levels in an organisation forcontinuously improving the quality of their service and safeguarding highstandards of patient care [6].ColonisationA person has a specific pathogenic organism, usually a multi-resistantorganisation (MRO) on or in the body without the production of an immuneresponse or disease. [2]ContactThe touching of any patient or their immediate surroundings or performing anyprocedure on a patient. [2]Contact precautionA transmission-based precaution used to interrupt the transmission of infectiousagents that are spread by direct or indirect contact with the patient or the patient’senvironment [2].Critical itemsA medical device that comes into contact with blood or normally sterile tissue andthat must be sterile at the time of use. Note: a critical medical device confers ahigh risk of infection if it is contaminated with microorganisms. [7]Droplet precautionA transmission-based precaution used to interrupt droplet transmission occurringfrom patients known or suspected to be infected with agents transmitted personto-person by respiratory droplets [2].Fit checkA check to ensure that the P2 / N95 mask is fitting each time it is put on [2].Functional areaA discrete location in a PHO that is designated for the delivery of patient servicese.g. Intensive Care Unit, Emergency Department, Cancer Centre, OutpatientClinic, Pharmacy, Physiotherapy Department, Dialysis Unit.Hand hygieneA general term applying to processes aiming to reduce the number ofmicroorganisms on hands. This includes application of a waterless antimicrobialagent (e.g. ABHR) to the surface of dry unsoiled hands; or use of soap / solution(plain or antimicrobial) and running water (if hands are visibly soiled), followed bypatting dry with single-use towels [2].PD2017 013Issue date: June-2017Page 2 of 30

Infection Prevention and Control PolicyPROCEDURESHW(s)Refers to all staff delivering or supporting healthcare services in a public healthorganisation. Any person employed or contracted by a NSW Health agency eitheron a permanent, temporary, casual, volunteer or agency basis.Healthcareassociated infection(HAI)Refers to infections acquired in healthcare facilities and infections that occur as aresult of healthcare interventions and which may manifest after people leave thehealthcare facility [2].Key partKey parts are those parts of equipment / instruments / consumables that ifcontaminated by infectious material increases the risk of infection. Contaminationmay occur by direct or indirect contact with the key site(s), other key-parts, orliquid infusions. [2]Key siteIs the area on the patient that must be protected from pathogenicmicroorganisms. Key Sites are medical device access sites, surgical sites or openwounds. [2]MonitorTo check, supervise, observe critically, or record the progress of an activity, actionor system on a regular basis in order to identify change.Health WorkerNegative pressureroomA single-occupancy patient-care room used to isolate persons with a suspected orconfirmed transmissible airborne communicable disease. Environmental factorsare controlled in negative pressure rooms to minimise the transmission ofinfectious agents that are usually transmitted from person to person by dropletnuclei associated with coughing or aerosolisation of contaminated fluids [2].The air handling system provides negative pressure by air flow into the room anddirect exhaust of air from the room to the outside of the building or recirculation ofair through a HEPA filter before returning to circulation. [2]Non-critical itemsA medical device that only comes into contact with intact skin. [7]OutbreakA state characterised by an increased incidence of an infection greater than whatis typically expected in a particular healthcare setting. The clustering of cases bymicroorganism, time, person and place may signal the possibility of an outbreak.Personal protectiveequipment (PPE)Refers to a variety of protective barriers used alone, or in combination, to protectmucous membranes, skin, and clothing from contact with recognised andunrecognised sources of infectious agents in healthcare settings.Point of careThe time and location where an interaction between a patient and clinician o

PD2005_414 Infection Control Program Quality Monitoring PD2007_036 Infection Control Policy PD2007_084 Infection Control Policy Prevention and Management of Multi-Resistant Organism PD2009_030 Infection Control Policy – Animals as Patients in Health Organisations PD2010_058 Hand Hygiene Policy. ATTACHMENTS 1. Infection Prevention and Control Policy: Procedures. Infection Prevention and .

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