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

Infection Prevention and Control Committee

in a Health Care Facility (HCF)

Christine Mukashema Infection Prevention and Control Manager, KFH

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

Functions of an Infection prevention and Control Committee in a Health care setting

1. Develops IPC education programmes for hospital staff

2. Strives to minimize the risks of health care associated infections (HCAI)

3. 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


6. 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


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


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

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.

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.

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

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

IPCC Membership:

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

• 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.

Meetings:

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

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

Responsibilities:

1. 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

2. 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.

3. 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, and3.3 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

Responsibilities:

5. Feedback of surveillance data to staff6. Review of the capabilities/practices of specific

departments: • Laboratory’s microbiological services • The CSSD• The Kitchen• The Laundry• Theatre

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

Responsibilities:

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

Infection Prevention and Control Audits in a Health Care Facility

Christine Mukashema Infection Prevention and Control Manager,

King Faisal Hospital

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

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

• 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

Background

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

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

• 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

IPC Audits Purpose

How to Audit:Setting of Standards and indicators

Hospital Service/DepartmentStandards All services and

departments must reach 100% compliance levels with IPC best practices

Each service/ department must reach full compliance

Indicators Proportion of services/departments who have reached 100% compliance

Degree of compliance of each service/department

Audit tools establishment

• Established an audit tools form• The criteria outlined in the tools vary

according to department

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

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

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

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

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

Root Causes: Possible causes of the IPC gaps

Policy on Audit not known

Form not yet known by some staff

IPC Audit gap

Management

Insufficient emphasis on importance of IPC Audit

from HOU, HoDs

Poor understanding of IPC needs?

Delayed/slow responses from Hosp. Admin. when a problem

is reported from the audit

People

Measurement Method Material

Policy

Staff still require education about IPC

Staff still require education re policies &

practices

Management of change issues

Problem reported not resolved for a

long time

Auditing not yet implemented in practice in

the hospital

Repeated stock outs

Ignorance on how to do audit

Processes need to be learned

Staff availability for education sessions

Policies not yet implemented

Financial issues

Possible causes of the IPC gaps

• Quality Problem identification• Specific Problem Statement

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

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.

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.

Monitor change & improvements

• Develop an action plan using a Project plan Template/tool

• Implement solutions - this requires careful planning, therefore the team must determine

Ex: Project plan Template/ ToolPLANNED

ACTIVITIESRESOURCESREQUIRED

RESPONSIBLEPERSON

ESTIMATED

START DATE

ACTUAL START DATE

ESTIMATED END

DATE

ACTUAL END DATE

COMMENTS

IPC Audits

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

Some IPC audits results

June 2009 Feb 2010 Sept 2010 June 2011 May 2012 Nov 2012 June 2013

65% 76% 81% 74% 73% 82% 88.8%


Departments Baseline Feb 2010 Sept 2010 June 2011 May 2012 Nov 2012 June 2013

IPC 51 79 99 91 73 87 85

NICU 62 76.6 87 92 93 91 98.3

ICU 71 84 96 94.5 81 89 97.7

OPD 57 77.6 83 88 79 83.4 81.8

Renal Service not yet established 64.5 87 87.5 92

Urusaro 62 65.9 84 88.5 81 89.7 98.3

Medical 46 75.5 76 77 69 83 91.2

Maternity 70 74.3 63 78 76 86.3 96


HDU Service not yet established 61 79 77

A&E 70 82.2 77 64.5 74 76 80

Surgical 40 63 71 52 57 63 78.9

Theatre 77 85.5 63 80 78 94 97

Pediatrics 63 64 63 80 77 86.8 85

CSSD 70 90.9 96 89 82 92 82

Physiotherapy 68 85 87 61 95 95 94.5

Dental 73 81 80 61 75 88.8 68


Pharmacy 57 76 84 72 93 82 85.5

Laboratory 66 72 90 77.5 70.5 82 89

Radiology 64 73 86 84 57 63 78.6

Maintenance 59 40 53 64 67 76 58

Kitchen 77 80 71 64 74 76 63

Laundry 67 86.3 90 84 53 76 74

Mortuary 48 72.7 67 57 57 76 78

Stores 56 82.9 90 54 54 76 78

Total 65 76 81 74 73 82.3 88%


IPC NICU ICU OPD Renal Urusaro MedicalMaternity0

20

40

60

80

100

120

IPC Audit results comparison 2009-2013

BaselineFeb-10Sep-10Jun-11May-12Nov-12Jun-13

Some IPC Audits results

HDU A&E Surgical Theatre Pediatrics CSSD PhysiotherapyDental0

20

40

60

80

100

120

IPC Audit result 2009-2013



Pharm

acy

Labor

ator

y

Radio

logy

Mai

nten

ance

Kitche

n

Laund

ry

Mor

tuar

y

Store

s0

10

20

30

40

50

60

70

80

90

100

IPC Audit results 2009-2013



IPC

NICU

ICU

OPD

Renal

Urusa

ro

Med

ical

Mat

erni

tyHDU

A&E

Surgi

cal

Theat

re

Pedia

trics

CSSD

Physiot

hera

py

Denta

l

Pharm

acy

Labor

ator

y

Radio

logy

Mai

nten

ance

Kitche

n

Laund

ry

Mor

tuar

y

Store

s0

20

40

60

80

100

120

Baseline

Feb-10

Sep-10

Jun-11

May-12

Nov-12

Jun-13

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

Conclusion

• IPC Audit will help in the monitoring and the evaluation of IPC activities

• Will help also in planning and making strategies for improvement if needed

‘To measure is To know’ “If you cannot measure it, you cannot improve it” Lord Kelvin1824-1907

Thank you!

• 0788830555• [email protected]