EMAS Matters The latest news and information for all EMAS staff
Issue 69, 09 December 2009
Raising our infection control standards Preparing for our next CQC inspection In last week’s issue of EMAS Matters we told you about the publication of a follow-up report by the Care Quality Commission (CQC) which made recommendations for infection control at EMAS to be improved. The findings are being taken extremely seriously because the safety of our patients and staff is a priority at EMAS. Staff across the organisation are now working hard to review our practices and make immediate changes and improvements ahead of the next inspection on 14 December. Already good progress is being made. In this special issue of EMAS Matters, we will be taking a look at how the issues raised are being addressed and how staff and teams at all levels of the organisation are responsible for ensuring that EMAS achieves and maintains the ‘gold standard’ in infection prevention and control.
New infection control reminder postcards One of the key areas of improving and maintaining our infection prevention and control standards is ensuring that all staff are aware of the policies and procedures in place.
In this issue...
Infection control standards Preparing for our next CQC inspection
Our responsibilities We all play a part
Addressing the issues Actions being taken
New Bio-Bins Improved clinical waste containers
Look out for our new infection control postcards…
To raise awareness of these and to help you remember the key aspects, a new reminder postcard has been produced. The handy pocket-sized card outlines the ‘Six Golden Rules’ of infection control such as hand hygiene and clean equipment. The reverse then reminds you of your ‘Core Responsibilities’ such as decontamination and dress code. We’ve had enough cards printed for every member of EMAS staff. Look out for the cards on your station within the next few days - and remember to keep it handy at all times.
“Every member of staff across EMAS has a part to play in making these improvements and achieving excellent standards of infection control in all aspects of our service. “I would like to thank staff for their hard work and support in this area so far - your efforts are greatly appreciated. “I know that together we can achieve the standards of cleanliness that people have the right to expect of us.”
...make sure you keep your copy handy
Paul Phillips, Chief Executive There’s more on page 2... www.emas.nhs.uk/insite
Our infection control responsibilities... Every person in EMAS has a responsibility to ensure that we achieve and maintain high levels of infection prevention and control standards. Here is a guide to who is responsible for what across EMAS: The Chief Executive and Trust Board Accountable for ensuring that there are effective arrangements in place to minimise the risks of healthcare associated infection within the Trust and for meeting the requirements of the Health and Social Care Act 2008 Code of Practice. The Director of Infection Prevention and Control (DIPC) Responsible for the Trust’s infection prevention and control strategy, ensuring implementation of the infection prevention and control programme and for providing assurance to the Trust Board and general public. The DIPC is the focal point for the integration of infection prevention and control into the Trust’s clinical governance systems and for ensuring the safety of patients from infection is high on the Trust’s agenda. The DIPC will liaise with external organisations ensuring the Trust is represented and best practice implemented. This role is undertaken by the Director of Nursing and Quality, Karen Glover. The Head of Infection Control and Quality Improvement Responsible for the development of infection prevention and control policies and any associated initiatives including management of inoculation injuries. They also liaise with the Organisational Learning and Communications teams to ensure this policy is effectively communicated to all appropriate personnel. Divisional General Managers Accountable for the implementation of the infection control policy in each Division including the provision and audit of ‘make ready’, domestic and vehicle cleaning services. The responsibility will be delegated to the Clinical Quality Managers. Infection Prevention and Control Group Responsible for overseeing and developing an EMAS strategy for the prevention and control of healthcare associated infections; and for the provision of information, instruction and training, performance monitoring and the management of inoculation injuries and the development of an infection control annual report. Clinical Quality & Governance Committee Responsible for approving and monitoring adherence to the Infection Control Policy and associated procedures.
All EMAS Employees Are responsible for familiarising themselves and complying with infection control policies and procedures. Directors, General Managers and Line Managers Responsible for ensuring they have a comprehensive understanding of their role as described in the infection control policy and any associated procedures or guidance. Including: Leading by example, particularly in relation to good hand hygiene Completion and monitoring of audits Ensuring their staff are familiar with the Infection Control Policy and Procedures Facilitating staff to complete training Ensuring staff involved in or affected by an inoculation incident are provided with adequate support Receipt and action of vehicle cleaning and other reports. Frontline Professionals Staff belonging to professional groups such as paramedics, technicians, emergency care practitioners etc are personally accountable for their standard of practice which must include compliance with the Trust’s infection control policy and procedures. In addition, registered professional staff are expected to challenge non compliance when observed to protect patients and promote patient safety. Specialist Teams (e.g. Clinical Services, Estates and Logistics, Risk & Safety, Operations and HR). All hold responsibilities for the prevention and control of infection and provision of specialist advice as outlined in the infection control policy and any associated procedures. Occupational Health Our occupational health provider Team Prevent provide specialist advice to the Trust on infection prevention and control within the scope of their expertise. Volunteers Are expected to familiarise themselves with the infection control policy and observe good hand hygiene practice at all times. Contracted Staff All contracted staff are expected to comply with the Trust’s infection control policies and procedures.
Responsibilities at-a-glance... The Chief Executive and Trust Board Accountable for ensuring that the risk of infection prevention and control is minimised across EMAS.
The Director of Infection Prevention and Control (DIPC) Karen Glover, Director of Nursing and Quality Responsible for the Trusts infection prevention and control strategy.
The Head of Infection Control and Quality Improvement Responsible for the development of infection prevention and control policies and initiatives.
Divisional General Managers Accountable for the implementation of the infection control policy in each Division.
Infection Prevention and Control Group Responsible for overseeing and developing an EMAS strategy for infection prevention and control.
Clinical Quality & Governance Comm Approving and monitoring adherence to the policy and procedures.
All EMAS Employees To be aware of and comply with the infection prevention and control policy and procedures.
Directors, General Managers and Line Managers Comprehensive understanding of infection control and leading by example.
Frontline Professionals Personally accountable for their standard of practice.
Specialist Teams Responsible for key areas of infection control and provision of specialist advice.
Occupational Health Provision of specialist advice.
Volunteers Awareness and adherence to the policy and procedures.
Contracted Staff Awareness and adherence to the policy and procedures.
Further information… To find out more contact the Infection Prevention and Control Team on 0115 884 5000.
There’s more on page 3...
Addressing the issues...
Last week we told you how the CQC had made recommendations for EMAS to improve infection prevention and control standards in seven key areas by 14 December. Here we take a look at those areas and see examples of how positive actions are being taken to improve standards:
A new type of clinical waste container is being introduced across EMAS to help improve how we dispose of healthcare waste.
CQC Report Recommendations
Examples of EMAS Actions
1. The trust must ensure that members of staff receive information on how to prevent and control infections. The trust must develop plans for the training and supervision of staff in how to prevent and control infections. This training and supervision must be implemented as soon as is reasonably practicable and priority must be given to staff who deliver care directly to patients.
12 month training plan developed to deliver mandatory training to all clinical staff. Training workbooks and Toolkits now issued to clinical staff. In every 24hour period, staff sign a schedule confirming that equipment has been cleaned and checked. Communications strategy in relation to cleanliness standards to be reinforced.
2. The trust must develop a programme of audit, to ensure that key policies and practices are being implemented appropriately.
Audit annual plan developed. Daily spotchecks of ambulance cleanliness and crew compliance with policy being carried out across EMAS. Station audits being carried out across EMAS.
3. The trust must ensure that all parts of the premises in which it provides healthcare are suitable for the purpose, kept clean and maintained in good physical repair and condition and must take immediate action to clean dirty vehicles.
Deep clean process now includes equipment cleaning. Date each vehicle was last deep cleaned now displayed in each vehicle to help prevent the time limit being exceeded. Deep clean checklists / cycle of all vehicles based at station displayed on station notice board.
4. The trust should continue making improvements to ensure that the cleaning arrangements detail the standards of cleanliness required in each part of its premises, including vehicles, and that a schedule of cleaning frequencies is publicly available.
All staff now aware that single use items should not be manually cleaned and re-used. All staff aware that equipment checklists must be completed.
5. The trust should continue making improvements to ensure it provides suitable handwashing facilities and antibacterial hand rub.
Gel toggles issued to all frontline staff. Gel dispensers available in all vehicles. Hand wipes available in all vehicles. Fob watches issued to all staff – supporting the ‘bare below the elbows’ policy.
6. The trust must ensure that reusable equipment is appropriately decontaminated and single-use equipment is disposed of after use. These processes should be subject to audit and assurance of practices.
Single use symbol now being emphasised across EMAS. Decontamination Procedure now displayed on all station notice boards.
7. The trust must ensure that it has and follows appropriate policies and protocols for the prevention and control of healthcareassociated infections, including the decontamination of reusable medical devices.
Signature sheets introduced to confirm Infection Control Policy has been read and understood by staff. Copy of EMAS’ Decontamination Procedure issued to each vehicle and station notice board.
To find out more contact the Infection Prevention and Control Team on 0115 884 5000.
Bio-Bins are for use when a vehicle does not have a rigid clinical waste container or a built-in clinical waste receptacle available - such as FRVs, cars, A&E or PTS vehicles. Bio-Bins are rigid re-sealable containers in 1 and 2 litre sizes and come in yellow and orange: Yellow Bio-Bin
High risk infectious waste Collection from station Deposit at hospital For high risk infectious waste (no sharps) when the patient is identified as infectious with a category ‘A’ condition (a full list is available on Insite). Or if the hospital only accept yellow containers. Orange Bio-Bin
Low risk infectious waste Collection from station Deposit at hospital For low risk infectious waste (no sharps) which can then be left at hospital where appropriate. When not possible, the yellow bins should be used. Once full, the bin should be sealed permanently using the self-adhesive strip. The bin can then be placed in standard yellow clinical waste container with other orange or yellow waste bins or bags. Bins should be changed at the end of every shift or when they have been filled to the maximum fill line. To ensure efficient waste management crew must also carry a black waste bag for domestic type waste and noncontaminated clinical packaging. For further information visit the Infection Control pages on Insite at www.emas.nhs.uk/insite.
EMAS Matters is produced by the Community Relations Team Thom Hall Assistant Communications Manager 0115 884 5131 email@example.com
EMAS Matters The newsletter for all EMAS staff