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1. Organisation of Infection Control
 

Introduction

Infection control (IC) is a quality standard and is essential for the well being and safety of patients, staff and visitors. It affects most departments of the hospital and involves issues of quality, risk management, clinical governance and health and safety.

An infection control programme with a firm structure should be in existence in all institutions that provide health care in order to establish a managed environment that

  • Secures the lowest possible rate of hospital acquired infection
  • Protects staff and visitors from unnecessary risks

The hospital manager or medical director is ultimately responsible for safety and quality within the hospital. He or she must ensure that appropriate arrangements are in place for effective infection control practices and that there is an Infection Control Team (ICT) and an Infection Control Committee (ICC). If the health care setting is too small to support such an organisation, experts in infection control should be available for consultation at regular intervals and when needed in an acute situation. Providers of home care should ensure that expertise in infection control is available for their staff.

Infection Control Team

The ICT should have a range of expertise covering knowledge of infection control, medical microbiology, infectious diseases and nursing procedures. The team should have a close liaison with the microbiology laboratory and ideally a microbiologist should be a member of the team.

The team should consist of at least one physician, the infection control officer (ICO), and at least one nurse, the infection control nurse (ICN). One ICN for 250 acute beds on a full-time basis was recommended in the US during the 1980s. A recent study in several different types of health care facilities reported 0.8 to 1.0 ICNs as adequate staffing. However the number of acute care beds is decreasing, out patient management, day surgery and home care are expanding, and problems of hospital infection and antibiotic resistance are increasing. Thus the optimal number of ICNs cannot be calculated simply on the basis of the number of acute care beds but rather depends on the case mix and workload. The number of ICOs in a team is probably best related to the number of ICNs: e.g. 1 to 5.

The team is responsible for day to day decisions on infection control as well as long term planning of infection control policy. It should meet several times a week or preferably daily. The team should be adequately funded to provide secretarial assistance, information technology capabilities, facilities and training materials, and to allow members to attend educational courses and professional meetings.

The composition and organisation of the ICT should take into account the local social and religious culture in the country concerned and the hierarchical structure of the hospital.

Infection Control Officer - duties and responsibilities

The ICO should preferably be a senior member of the hospital staff with experience and training in infection control, such as a medical microbiologist, epidemiologist or infectious diseases physician. In the absence of one of these, a surgeon, paediatrician or other appropriate physician with special interest in the field could be appointed. Whichever person is appointed, they must be guaranteed the extra time needed to fulfil the responsibility of an Infection Control Officer. The ICO is usually the chairman of the Infection Control Committee and is responsible to the hospital manager or medical director for infection control in the health care setting.

Infection control nurse - duties and responsibilities

The ICN should be able to function as a clinical nurse specialist. The duties of the ICN are primarily associated with IC practices with special responsibility for nursing problems and education.

In a large hospital the ICN can train link' nurses. These individuals have special responsibility for maintaining good infection control practices and education within their clinical departments. This person is the "link" between the ICN and the ward and helps identify problems, implement solutions and maintain communications.

Basic qualifications of the ICN

A registered nurse (or equivalent qualified person) with clinical and administrative expertise. Good interpersonal and educational skills are important. Recognised training in IC is essential.

Infection control committee

The need for an ICC depends on the structure of the health care setting. In smaller hospitals, the ICC may report directly to the senior hospital management committee; in larger ones it may be a subcommittee of a risk management or clinical governance committees. It should be made up of representatives from various hospital departments. All the clinical departments should be represented, together with members of other key departments, such as occupational health, catering, cleaning, facilities/buildings and management. The committee should act as a liaison between departments responsible for patient care and supportive departments (e.g., pharmacy, maintenance). Its aim should be to improve hospital IC practice and recommend appropriate policies, which should be subject to frequent review.

The committee should be responsible to the hospital manager or medical director and should have a physician, preferably the infection control officer or hospital epidemiologist as a chairman. The hospital manager and the chief nursing officer, or their representatives, should attend meetings. The size of the committee will vary depending on the requirements of the hospital. The departments should nominate their representatives and if not the departmental head, the representative should be in a position to make decisions.

The committee should hold regular minuted meetings and the minutes should go to the Medical Director and the Hospital Management Board as well as to departments directly involved in the subjects discussed during the meeting. It should produce an annual report and an annual business plan for infection control.

The following are the most important activities to ensure adequate infection control practices where health care is provided.

  • Provide facilities and equipment that make it possible for the staff to maintain good infection control practices.
  • Produce standards (policies, guidelines) for procedures or systems used within the health care setting
  • Implement educational programmes for all personnel in the use of such standards.
  • Establish surveillance systems that identify problem areas.
  • Produce a policy for the prudent use of antibiotics and work to ensure adherence to the policy.
  • Produce guidelines for cleaning, disinfection and decontamination and work to ensure adherence to those guidelines.

Infection control is the responsibility of every individual in the healthcare facility. However, the hospital management and the infection control team can provide expertise, education and support to help staff maintain proper standards and minimise the risks of infection.

Responsibilities of the health care provider

  • Ensure facilities are available to the hospital staff to maintain good infection control practices.
  • Ensure an infection control team is available.
  • Support the activities of the infection control team

Responsibilities of the infection control team

  • Advise staff on all aspects of infection control and maintain a safe environment for patients and staff
  • Provide educational programmes on the prevention of hospital infection for all hospital personnel
  • Provide a basic manual of policies and procedures and ensure that local written guidelines based on these are in existence.
  • Establish systems of surveillance of hospital infection in order to identify at-risk patients and problem areas that need intervention. Methods for surveillance may include case finding by ward rounds and chart reviews, reviews of laboratory reports, and targeted prevalence or incidence surveys.
  • Advise management of patients requiring special isolation and control measures.
  • Investigate and control outbreaks of infection in collaboration with medical and nursing staff.
  • Ensure that an antibiotic policy is in existence.
  • Liaise with the hospital doctors and administration (managerial and nursing), community health doctors and nurses, and infection control staff in adjacent hospitals.
  • Provide relevant information on infection problems to management and the ICC.
  • Perform other duties as required, e.g., kitchen inspections, pest control, waste disposal.

Examples

Topics of importance for a procedure manual

Patient care

  • Hand hygiene
  • Isolation practices
  • Invasive procedures (intravascular, urinary catheterisation, mechanical ventilation, tracheostomy care, and wound management).
  • Oral alimentation

Ward specific procedures

  • Isolation procedures for infectious patients
  • Surgical and operating theatre techniques
  • Obstetrical, neonatal, and intensive care techniques

Production of items of critical importance

  • Sterilisation and disinfection
  • Medication and infusion preparation (including blood products)

Staff health

  • Immunization
  • Post-exposure management for employees, patients and others exposed to infectious diseases within the facility

Investigation and management of specific infections

  • Methicillin resistant Staphylococcus aureus (MRSA)
  • Diarrhoea
  • HIV
  • Tuberculosis
  • Multiresistant Gram-negative bacteria

Details of components of safe environment for patients and staff

Responsibility of the hospital manager

  • Ensure a safe, clean environment.
  • Ensure the availability of sterile water for invasive procedures.
  • Ensure the availability of safe food.
  • Ensure the availability of an air supply appropriate for the level of surgery provided.

Responsibility of the infection control team

  • Provide advice on general architectural features (e.g. operating and isolation rooms).
  • Provide advice on clean water and proper facilities for handwashing and drinking.
  • Arrange for the separation of clean and dirty materials and procedures (e.g., storage of sterile supplies in a room separate from one used for reprocessing of dirty equipment or storage of waste).
  • Provide written policies for critical elements of infection control.

Minimal administrative requirements

  • A physician and a nurse with responsibilities for infection control.
  • A manual of critical infection control policies.
  • An educational programme for staff.
  • A clear line of responsibility to the senior management of the hospital.
 
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