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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
Functions of an Infection prevention and Control Committee in a Health care setting
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
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
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
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%
Some IPC audits results
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
Some IPC audits results
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
Some IPC audits results
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%
Some IPC audits results
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
BaselineFeb-10Sep-10Jun-11May-12Nov-12Jun-13
Some IPC Audits results
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
BaselineFeb-10Sep-10Jun-11May-12Nov-12Jun-13
Some IPC Audits results
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]