Infection Prevention and Control Committee in a Health Care Facility (HCF) Christine Mukashema Infection Prevention an

1. Infection Prevention and Control Committee in a Health Care Facility (HCF)Christine Mukashema Infection Prevention and Control Manager, KFH

2. Objectives • Understand the importance for an Infection Prevention and Control Committee (IPCC) in a Health Care Facility (HCF) • Describe the reasons for creating an Infection Prevention and Control Committee in a HCF

3. Functions of an Infection prevention and Control Committee in a Health care setting • Develops IPC education programmes for hospital staff • Strives to minimize the risks of health care associated infections (HCAI) • Formulates, implements and revises infection control policies and procedures 4. Discusses any infection prevention and control related problems brought to them 5. Advises on the purchase of equipment where applicable

4. Functions of an Infection prevention and Control Committee in a Health care setting • Reports on the incidence and prevalence of alert organisms, important infectious diseases 7. Reviews outbreaks of infection and advice on how outbreaks must be managed and might be prevented 8. Assists in the planning and development of services and facilities in the hospital that are relevant to infection control

5. Functions of an Infection prevention and Control Committee in a Health care setting 9. Monitors and advises on specific areas for hygiene and infection control e.g. catering, CSSD, ventilation, water services, occupational health, pharmacy, theatre, endoscopies etc 10. Receives the monthly report of infection control statistics from different service units within the facility 11. Ensures that reports are acted upon by management

6. Functions of an Infection prevention and Control Committee in a Health care setting 12. Ensures compliance with standards in respect of infection prevention and control services 13. Promotes co-operation between departments regarding infection prevention and control 14. Advises management on all aspects of infection control in the hospital 15. Documents visits to clinical and non clinical areas and report at regular intervals as prescribed by hospital policy

7. Terms of Reference A competent and active infection prevention and control committee is a most important part of any programme for prevention and control of health care associated infections (HCAI) among patients and personnel.

8. IPCC Membership: The Infection Prevention and Control Committee (IPCC), is a multi-disciplinary committee. It includes representation from the Hospital administration, Department of Nursing, Medical Staff, and the Infection Control Department.

9. IPCC Membership: • The committee members are representatives of the following departments: • Senior Management • The department of Nursing • The department of Clinical Medicine • Medical ward • Surgical ward • Paediatric ward • Maternity ward • Theatre/CSSD • OPD • Dental Department • The Occ H&S Service • Laboratory • The Infection Control Nurse • Pharmacy • House keeping • Laundry • Catering

10. IPCC Membership: • The Chairperson shall be elected by the committee on a yearly basis • Representation from Maintenance, Health Records, and other ancillary staff will be used on a consultative basis

11. Meetings: • The committee shall meet twice a month • Meetings shall be held with more than one half (50%) of the members present, otherwise the meeting shall continue as an ad hoc meeting • If two successive ad hoc meetings occur, binding decisions may be taken in the second meeting

12. Meetings: • Minutes of the meetings and documentation of the recommendations made shall be kept and submitted to the Senior Management Committee within one week of a meeting.

13. Lines of communication: • The IPCC must be a subcommittee of the Senior Management Committee • The Chairman has the authority to institute appropriate control measures or studies when there is considered to be a danger to patients or personnel

14. Authority: • The IPPC has the authority to demand compliance with IPC policies and guidelines in all departments • Hospital department managers have line responsibility for implementation of these policies

15. Responsibilities: • Recommendation on all aspects of hospital policy relating to infection prevention and control. Administration is responsible for prompt review and implementation of recommended infection control policy formulated by the committee • Review of all data concerning infections and infection risks. Through the Infection Control Nurse, the Infection Control Committee shall be kept informed of infections within and outside the hospital of epidemiological significance.

16. Responsibilities: • Initiation and supervision of the investigations and the reporting of: 3.1 clusters of infections above expected levels, 3.2 single cases of unusual nosocomial infections, and 3.3 other infection control studies and surveys. 4. Initiation of audits of the Hospital’s IPC practices and submission of the related reports to Senior Management

17. Responsibilities: 5. Feedback of surveillance data to staff 6. Review of the capabilities/practices of specific departments: • Laboratory’s microbiological services • The CSSD • The Kitchen • The Laundry • Theatre

18. Responsibilities: 7. Approval of all chemicals used for disinfection and all methods used for sterilization within the hospital 8. Recommendations for the purchase/ provision of all IPC equipment 9. Recommendations related to the educational needs of hospital staff in relation to IPC

19. Possible IPC Activities • Surveillance • Clinical waste management quality project • Hand hygiene audit • Three data collection exercises • Infection control practices general audit • Notification of wound and other sepsis • Hand washing techniques audit

20. Infection Prevention and Control Audits in a Health Care Facility Christine Mukashema Infection Prevention and Control Manager, King Faisal Hospital

21. Learning Objectives • Indicate the role of an IPC Audit in a health care setting • List some of the use of the IPC Audit data • Discuss the importance of the IPC Audit of a Health care settings

22. Background • Infection prevention and control (IPC) is an important dimension of safe care and an integral aspect of day-to-day care • It is a hospital-wide function and is the responsibility of those providing service • Thus everyone working in a healthcare facility (HCF) has a part to play in ensuring the implementation of Infection Prevention and Control standards

23. Background • Non compliance to infection control standards and guidelines is associated with increase in Health Care Associated Infections (Rockville 2008) • Infection control audits to evaluating clinical practice is one of the most effective strategies in the prevention of HCAIs (Madani, 2006) • The study aimed to determine the impact of infection control audits on infection control standards compliance

24. Principle goals for IPC • To protect the patient • To protect the healthcare worker (HCW), visitors, and others in the healthcare environment • To accomplish the above in a cost effective manner, wherever possible. • The level of IPC service is a good indicator of the standard of excellence of the care provided

25. IPC Audits Purpose • There are several reasons for conducting an IPC Audit • Generally it is hoped that the results will contribute to: • The delivery of safe health care; • Provision of an environment that drives improvement in quality, safety and accountability; • An audit will help to establish the level of IPC service as a baseline for improvement

26. IPC Audits Purpose • Establish the current infection control practices used across the hospital • Promotion of continuous quality improvement through regular monitoring and evaluation of IPC services; and attainment of best practices in IPC • Identify the gap between those current practices and international standards • Provide baseline data for further development of an IPC Service

27. How to Audit:Setting of Standards and indicators

28. Audit tools establishment • Established an audit tools form • The criteria outlined in the tools vary according to department

29. IPC Audits • Following receipt of the initial results, monthly departmental internal audits should be completed by the department managers or their delegate, and the infection control Link Personnel

30. Departments to be assessed • Infection Prevention &Control • Neonatal Intensive Care Unit • Intensive Care Unit • Out Patients Department • Accident & Emergency • Surgical • Urusaro • Medical • Paediatrics • Central Sterile Supply Department • Physiotherapy • Dental • Pharmacy • Laboratory • Radiology • Maintenance • Kitchen • Laundry • Mortuary • Stores • Maternity • Theatre

31. Important Criteria to be assessed • Administration • Audit • IPC Committee • Education • Risk Management • IPC Guidelines/ Standards • Clinic /dressing room • Kitchens • Housekeeping • Hand washing • Isolations precautions • Linen management • Waste management • Environmental hygiene • Bathrooms/Showers/Toilets • Sluice room • Urinary catheters

32. Criteria to be assessed • Respirator equipment • Scrub up rooms • Ventilation • Autoclave • Protective clothing • Patient’s personal hygiene • Layout • Storage • Biosafety cabinet • Change rooms • Aseptic technique • Specimens • Equipment • Cleaning material • Disinfectants • Refrigerators • Food hygiene • Staff • Water supply • Hydrotherapy pool • Intravascular devices

33. IPC Audit data analysis • The IPC Audit data will help in identifying IPC issues in different areas which will include: • Management • People • Policies • Material • Measurement, and • Method

34. Root Causes: Possible causes of the IPC gaps Management Policy People Poor understanding of IPC needs? Staff availability for education sessions Problem reported not resolved for a long time Insufficient emphasis on importance of IPC Audit from HOU, HoDs Staff still require education about IPC Delayed/slow responses from Hosp. Admin. when a problem is reported from the audit Staff still require education re policies & practices IPC Audit gap Auditing not yet implemented in practice in the hospital Management of change issues Processes need to be learned Repeated stock outs Policies not yet implemented Financial issues Ignorance on how to do audit Method Material Measurement

35. Possible causes of the IPC gaps • Quality Problem identification • Specific Problem Statement

36. IPC Compliance • An assessment of 80% or above reflects compliance to IPC best practices that represents the desired state to which the whole hospital and each department or service must work toward achieving

37. Choose possible solutions • Unless the problem in question is the sole responsibility of an individual, developing solutions should be a team effort. • Although solutions are of different natures, often, they are rooted in management systems related to supervision, training and logistics.

38. Monitor change & improvements • Teams should modify solutions as needed and should fully document the results and lessons learned. • Once the solution has proved to be effective, the new process must be documented and disseminated so that others can learn from the experience.

39. Monitor change & improvements • Develop an action plan using a Project plan Template/tool • Implement solutions - this requires careful planning, therefore the team must determine

40. Ex: Project plan Template/ Tool

41. IPC Audits • IPC Audits should be done every months and comparison should be done for improvements

42. Some IPC audits results

43. Some IPC audits results

44. Some IPC audits results

45. Some IPC audits results

46. Some IPC audits results

47. Some IPC Audits results

48. Some IPC Audits results

49. Some IPC Audits results

50. Recommendations • Regular infection control audits in all healthcare facilities • Infection control audits to form part of our hospital’s quality improvement processes • Forums for sharing knowledge and information