General Note
NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out. New policies will be subject to a review date of no more than 1 year from the date of first issue.
Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.
If a policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published, or if national policy or legislative changes are made
1. FUNCTION
The purpose of this overarching policy is to ensure that responsibility for prevention and control of Healthcare Associated Infection (HAI) is embedded at all levels of the organisation and to clarify the responsibilities as laid down in national directives for prevention and control of infection, from the Chief Executive and Board through to individual practitioners.
It describes the processes to prevent healthcare associated infections that will be implemented within NHS Fife to ensure the application of the highest standards in accordance with the requirements of NHS Healthcare Improvement Scotland (HIS), the strategic direction laid down in the Healthcare Associated Infection (HAI) Standards (2015) and Healthcare Associated Infection and Antimicrobial Resistance (AMR) Policy Requirements DL (2019) 23 or any relevant updates to these documents.
It is supported by the mandated NHSScotland National Infection Prevention and Control Manual (2021) (NIPCM) and the NHS Fife Infection Prevention and Control Manual (FIPCM).
2. LOCATION
This policy applies to all staff within all the component parts of NHS Fife and Fife Health & Social Care Partnership (HSCP) whether working in healthcare premises, domiciliary settings or other locations where healthcare services are being delivered. It also applies to private and independent contractors working on NHS Fife premises, including GPs in community hospitals, locum and agency staff, and volunteers. It is offered as best practice guidance for independent contractors on their own premises.
3. RESPONSIBILITY
3.1. NHS Fife Board
Responsibilities of the Board are laid down in Healthcare Associated Infection (HAI) Standards February 2015 (as amended).
3.1.1 The Board must:
Ensure the organisation demonstrates leadership and commitment to infection prevention and control to promote a culture of continuous quality improvement.
Ensure executive leaders and their teams have a working knowledge, appropriate to their role in the organisation, of the infection prevention and control policies and procedures as well as the national and local priorities that impact on care within the organisation. This includes all the elements set out in Appendix 1.
3.1.2. These responsibilities are discharged through the establishment of the following posts and structures:
• Director of Public Health
• Public Health Consultant in Communicable Disease and Environmental Health
• Executive Lead for Infection Control
• Executive Lead for Decontamination
• Infection Control Committee Structure
3.2. Board Chief Executive
The Chief Executive has overall responsibility for the provision of infection control within NHS Fife.
The responsibilities of the Chief Executive with respect to infection control are laid down in HDL 2005 (8) and are set out in full in Appendix 2.
3.3. Executive Lead for Infection Control
Reports to the NHS Fife Chief Executive and is responsible for ensuring the delivery of the Board’s key responsibilities relating to prevention and control of infection and HAI.
The Executive Lead’s responsibilities are set out in full in Appendix 3.
3.4. Infection Control Manager (ICM)
Appointment to this post was made in response to HDL (2001)10 with the role and responsibility of the ICM being further defined in HDL 2005 (8).
The ICM’s responsibilities are set out in full in Appendix 4.
3.5. Infection Control Doctors (ICD)
The role and function of the Infection Control Doctors (ICD) is to provide strategic leadership in conjunction with the ICM and Senior Infection Prevention and Control Nurse (SIPCN) for infection prevention and control to NHS Fife.
The ICD’s responsibilities are set out in full in Appendix 5.
3.6. Infection Prevention & Control Team (IPCT)
The IPCT provides expert reactive and proactive advice and information to all staff within all the component parts of NHS Fife, HSCP and to private and independent contractors working on NHS Fife premises, including GPs in community hospitals, locum and agency staff, and volunteers. Full responsibilities are set out in Appendix 6.
3.7. Infection Control Committee (ICC)
The Terms of Reference (TOR) for the ICC set the parameters of their responsibilities, full details of which are set out in Appendix 7.
3.8. Directors, General Managers and Line Managers are responsible for ensuring they have a comprehensive understanding of their own remit within this policy and associated procedures and guidance laid down in the Infection Prevention and Control Manual. Their explicit responsibilities are set out in Appendix 8.
3.8.1. The role of the Charge Nurses/Ward Leaders/Team Leader in infection control is further defined within HDL (2005)7 and includes the following: -
1. Must have undertaken the ‘Cleanliness Champions’ educational programme or SIPCEP equivalent.
2. Should ensure that all nurses have Personal Development Plans (PDP) that contain specific objectives for continuing professional development in HAI.
3. Are expected to set sensible limits on visiting, ensuring that visitors don’t sit on beds, minimising the risk to patients.
4. Are responsible for ensuring that any local or national infection control guidance is implemented within their areas.
5. Should have the authority to require local domestic services to act timely on any problems identified.
6. Charge nurses should be involved in auditing compliance with infection control policies and cleaning schedules within their areas.
3.9. All members of staff
Staff have a responsibility to demonstrate an acceptable level of competence in the workplace relating to control of HAI.
They must:
1. Ensure they have received appropriate infection prevention and control training including hand hygiene instruction in the last twelve months and fully adhere to Hand Hygiene Standard Operating Procedures (SOPs).
2. Never knowingly place a patient, member of staff or visitor at risk from an infection.
3. Work to the infection control and related standards set out in the NHS Fife’s infection control policy and the mandated NIPCM.
4. Adopt national evidence-based guidance in order to ensure patients are treated according to best practice.
5. Challenge poor infection prevention and control practice and seek support from the IPCT as required.
6. Communicate proactively and reactively with the IPCT ensuring clear lines of communication.
7. Obtain advice from the IPCT or Occupational Health if they are concerned over their own risks.
4. OPERATIONAL SYSTEM
The aim of this policy statement is to ensure that NHS Fife provides a management process and framework under which all infection control activities will operate.
This policy is underpinned by the National Infection Prevention and Control Manual, which details standard operating procedures and guidance for all aspects of infection prevention and control and is an integral part of this policy statement. All staff must be made aware of this document. It is also supported by the Prevention and Control of Infection Annual Work Programme, and the NHS Fife Prevention and Control of Infection Annual Report.
4.1. The following functional arrangements for infection control are defined within the Health Improvement Scotland (HIS) IPC Standards 2022 (as amended) namely:
1. The Prevention and Control of Infection Annual Work Programme
2. The Prevention and Control of Infection Annual Report
3. The National Infection Prevention and Control Manual
The full operational system for these issues is set out in Appendix 9.
4.2.1 The National Infection Prevention and Control Manual covers:
• Chapter 1 – Standard Infection Control Precautions (SICPs)
• Chapter 2 – Transmission Based Precautions (TBPs)
• Chapter 3 - Healthcare Infection Incidents, Outbreaks and data Exceedance
• Chapter 4 – Infection Control in the Built Environment and Decontamination
• Addendum for Infection prevention and Control within Neonatal Settings (NNU)
• A-Z Pathogens
• Infection Prevention and Control Manual for Older People and Adult Care Homes
• Appendixes
• Resources (including Literature Reviews)
The NIPCM is mandatory for NHSScotland. In all other care settings, to support with health and social care integration, the content of this manual is considered best practice. The Infection Prevention and Control Manual for Older People and Adult Care homes is mandatory within the care home setting.
4.2.2. The NHS Fife Infection Prevention and Control Manual covers:
1. Staff health
2. Standard Infection Control Precautions and Transmission Based Precautions
3. Outbreak Management
4. Infection Control Guidelines on ice for patients
5. Pets in Hospital
6. Food preparation, storage and handling
7. Specimen handling
8. Care at the Point of Death - Last Offices
9. Epidemiology: important organisms and diseases
10. Principles of decontamination
Manual sections are reviewed on a rolling programme (and more frequently if national guidance changes) and the programme of reviews for the forthcoming year will be documented in the Prevention and Control of Infection Annual Work Programme.
5. RISK MANAGEMENT
5.1. The risk to staff, patients and visitors will be managed by the application of the procedures laid down in the National Infection Prevention and Control Manual
5.2. Risks will be documented in the Infection Prevention and Control Risk Register and reviewed bimonthly by the ICC.
5.3. Governance arrangements are laid down in the NHS Fife Prevention and Control of Infection Implementation Framework 2022-24 and risks will be escalated in line with the pathways laid down in that document.
6. APPENDICES
Appendix 1 - Responsibilities of the Health Board
Appendix 2 - Responsibilities of the Board Chief Executive
Appendix 3 - Responsibilities of the Executive Lead for HAI: Infection Control
Appendix 4 - Responsibilities of the ICM
Appendix 5 - Responsibilities of an ICD
Appendix 6 - Responsibilities of the IPCT
Appendix 7 - Responsibilities of the ICC
Appendix 8 - Responsibilities of Directors, General Managers and Line Managers
Appendix 9 - Documents underpinning and supporting the Infection Control Policy
7. RELATED DOCUMENTS
National Infection Prevention and Control Manual
NHS Fife Infection Prevention and Control Manual
NHS Fife Prevention and Control of Infection Implementation Framework 2019-2021
8. REFERENCES
DL (2019) 23 Healthcare Associated Infection and Antimicrobial Resistance (AMR) Policy Requirements
HIS IPC Standards (2022)
National Infection Prevention and Control Manual (2015)
SGHSCD HAI Taskforce Delivery Plan (2011)
NHSScotland National Cleaning Services Specification (2016)
SHFN 30: Part A & Part B (2014)
HDL (2001)10 Decontamination of Medical Devices
HDL (2005) 7 Infection Control and Cleaning: Nursing Issues
HDL (2005) 8 Infection Control: Organisational Issues
Health and Safety at Work etc. Act 1974
Management of Health and Safety at Work Regulations 1999 (as amended)
The Public Health (Control of Disease) Act 1984;
The Public Health (Infectious Diseases) Regulations 1988;
Personal Protective Equipment at Work Regulations 1992 (as amended);
Control of Substances Hazardous to Health Regulations 2002 (as amended);
Infection Control in Adult Care Homes: Final Standards, 2005;
The Food Safety Act 2009;
The Food Safety Regulations – Regulation (EC) No 852/2004 in the Hygiene of Food
stuffs and The Food Hygiene (Scotland) Regulation 2006.
