Presentation on theme: "Infection Prevention and Control Committee in a Health Care Facility (HCF) Christine Mukashema Infection Prevention and Control Manager, KFH."— Presentation transcript:
1 Infection Prevention and Control Committee in a Health Care Facility (HCF) Christine Mukashema Infection Prevention and Control Manager, KFH
2 ObjectivesUnderstand 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 staffStrives to minimize the risks of health care associated infections (HCAI)Formulates, implements and revises infection control policies and procedures4. Discusses any infection prevention and control related problems brought to them5. 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 diseases7. Reviews outbreaks of infection and advice on how outbreaks must be managed and might be prevented8. 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 ReferenceA 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 ManagementThe department of NursingThe department of Clinical MedicineMedical wardSurgical wardPaediatric wardMaternity wardTheatre/CSSDOPDDental DepartmentThe Occ H&S ServiceLaboratoryThe Infection Control NursePharmacyHouse keepingLaundryCatering
10 IPCC Membership:The Chairperson shall be elected by the committee on a yearly basisRepresentation 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 meetingIf 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 CommitteeThe 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 departmentsHospital 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 committeeReview 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 expectedlevels,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
17 Responsibilities: 5. Feedback of surveillance data to staff 6. Review of the capabilities/practices of specific departments:Laboratory’s microbiological servicesThe CSSDThe KitchenThe LaundryTheatre
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 SurveillanceClinical waste management quality projectHand hygiene auditThree data collection exercisesInfection control practices general auditNotification of wound and other sepsisHand washing techniques audit
20 Infection Prevention and Control Audits in a Health Care Facility Christine MukashemaInfection Prevention and Control Manager,King Faisal Hospital
21 Learning ObjectivesIndicate the role of an IPC Audit in a health care settingList some of the use of the IPC Audit dataDiscuss the importance of the IPC Audit of a Health care settings
22 BackgroundInfection prevention and control (IPC) is an important dimension of safe care and an integral aspect of day-to-day careIt is a hospital-wide function and is the responsibility of those providing serviceThus everyone working in a healthcare facility (HCF) has a part to play in ensuring the implementation of Infection Prevention and Control standards
23 BackgroundNon 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 patientTo protect the healthcare worker (HCW), visitors, and others in the healthcare environmentTo 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 PurposeThere are several reasons for conducting an IPC AuditGenerally 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 PurposeEstablish the current infection control practices used across the hospitalPromotion of continuous quality improvement through regular monitoring and evaluation of IPC services; and attainment of best practices in IPCIdentify the gap between those current practices and international standardsProvide baseline data for further development of an IPC Service
27 How to Audit: Setting of Standards and indicators HospitalService/DepartmentStandardsAll services and departments must reach 100% compliance levels with IPC best practicesEach service/ department must reach full complianceIndicatorsProportion of services/departments who have reached 100% complianceDegree of compliance of each service/department
28 Audit tools establishment Established an audit tools formThe criteria outlined in the tools vary according to department
29 IPC AuditsFollowing 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 &ControlNeonatal Intensive Care UnitIntensive Care UnitOut Patients DepartmentAccident & EmergencySurgicalUrusaroMedicalPaediatricsCentral Sterile Supply DepartmentPhysiotherapyDentalPharmacyLaboratoryRadiologyMaintenanceKitchenLaundryMortuaryStoresMaternityTheatre
31 Important Criteria to be assessed AdministrationAuditIPC CommitteeEducationRisk ManagementIPC Guidelines/ StandardsClinic /dressing roomKitchensHousekeepingHand washingIsolations precautionsLinen managementWaste managementEnvironmental hygieneBathrooms/Showers/ToiletsSluice roomUrinary catheters
32 Criteria to be assessed Respirator equipmentScrub up roomsVentilationAutoclaveProtective clothingPatient’s personal hygieneLayoutStorageBiosafety cabinetChange roomsAseptic techniqueSpecimensEquipmentCleaning materialDisinfectantsRefrigeratorsFood hygieneStaffWater supplyHydrotherapy poolIntravascular devices
33 IPC Audit data analysis The IPC Audit data will help in identifying IPC issues in different areas which will include:ManagementPeoplePoliciesMaterialMeasurement, andMethod
34 Root Causes: Possible causes of the IPC gaps ManagementPeoplePolicyPolicy on Audit not knownForm not yet known by some staffPoor understanding of IPC needs?Staff availability for education sessionsProblem reported not resolved for a long timeInsufficient emphasis on importance of IPC Audit from HOU, HoDsStaff still require education about IPCDelayed/slow responses from Hosp. Admin. when a problem is reported from the auditStaff still require education re policies & practicesIPC Audit gapAuditing not yet implemented in practice in the hospitalProcesses need to be learnedManagement of change issuesRepeated stock outsPolicies not yet implementedIgnorance on how to do auditFinancial issuesMeasurementMethodMaterial
35 Possible causes of the IPC gaps Quality Problem identificationSpecific Problem Statement
36 IPC ComplianceAn 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/toolImplement solutions - this requires careful planning, therefore the team must determine
40 Ex: Project plan Template/ Tool PLANNED ACTIVITIESRESOURCESREQUIREDRESPONSIBLEPERSONESTIMATED START DATEACTUAL START DATEESTIMATED END DATEACTUAL END DATECOMMENTS
41 IPC AuditsIPC Audits should be done every months and comparison should be done for improvements
42 Some IPC audits results June 2009Feb 2010Sept 2010June 2011May 2012Nov 2012June 201365%76%81%74%73%82%88.8%
43 Some IPC audits results DepartmentsBaselineFeb 2010Sept 2010June 2011May 2012Nov 2012June 2013IPC51799991738785NICU6276.6929398.3ICU71849694.5818997.7OPD5777.6838883.481.8RenalService not yet established64.587.5Urusaro65.988.589.7Medical4675.576776991.2Maternity7074.3637886.3
44 Some IPC audits results HDUService not yet established617977A&E7082.264.5747680Surgical406371525778.9Theatre85.5789497Pediatrics6486.885CSSD90.996898292Physiotherapy68879594.5Dental73817588.8
45 Some IPC audits results Pharmacy57768472938285.5Laboratory669077.570.589Radiology6473866378.6Maintenance5940536758Kitchen77807174Laundry86.3Mortuary4872.778Stores5682.954Total658182.388%
50 RecommendationsRegular infection control audits in all healthcare facilitiesInfection control audits to form part of our hospital’s quality improvement processesForums for sharing knowledge and information
51 ConclusionIPC Audit will help in the monitoring and the evaluation of IPC activitiesWill 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 Kelvin