Infection Prevention & Control
Summary of Infection Control programme at the Mater Private Hospital
The Infection Control Programme has been gradually expanding since it’s inception in 1995 with the appointment of an Infection Control Nurse (ICN) to liase with the Infection Control Doctor (ICD)
They began their programme with initial audit of practice in each of the main areas of the hospital in order to establish current practice and provide a starting point from which guidelines could be produced.
Formal audit of wound infection rates and rates of hospital acquired MRSA were audited throughout 1996 and in July of that same year the Infection Control committee was established. The programme has been reviewed annually and has been continuously evolving since then.
Structure of Infection Control Committee
Chair person – Consultant Microbiologist/ Infection Control Doctor
Secretary – Infection Control Nurse
Members - Nursing Executive team representative
Hospital executive team representative
Consultant Anaesthetist/ Intensivist
Theatre/Day services –Divisional Nurse Manager
Theatre Infection Control Liaison manager
Technical Services Manager/Safety manager
Occupational Health Physician
Chief Pharmacist
Ward liaison pharmacist
I.T.U. manager
C.S.S.D. supervisor
Functions of the Infection Control Committee
- To establish policy for infection control and prevention
- To update and revise these policies as necessary based on current scientific knowledge, accepted practice guidelines and applicable law and regulation
- To set criteria for defining nosocomial infections, data collection methods and reporting processes
- To review the information obtained from surveillance and advise change of practice where deemed necessary.
- To identify and investigate outbreaks of infection
- To establish policies for dealing with specific infections and for care of patients with specific infections
- To act in an advisory capacity on matters of infection control and prevention
- To establish hospital policy for cleaning, sterilisation and disinfection of equipment
- To define policy for safe handling and disposal of waste
- To advise on the education and training needs of staff regarding the prevention and management of infection
Communication structures
- The committee convenes 4-5 times annually. Minutes of each meeting are sent to the Quest Committee for their comments on issues of relevance and in order to keep them informed of the work of the committee.
- A summary report is sent to the Hospital Board each quarter.
- Issues of specific interest to staff are communicated via hospital news letter, Intranet site, memos and regular personal visits to wards and departments.
- Results of audits and surveys are sent directly to ward/department managers at least annually and when issues of relevance arise. They are sent on a yearly basis to consultants.
- Wards are visited by the Infection Control Nurse at least 3 times each week in order to encourage staff to discuss issues relating to infection control and wound management. This also aids prompt identification of infection control issues.
The Infection Control Nurse is also invited to attend departmental meetings in order to update staff on specific issues. For example, the theatre staff invite the Infection Control Nurse to attend their meetings about 3 times each year in order to up date them on infection rates and trends.
Education Programme
The Infection Control education programme is a hospital wide programme. Each new staff member, regardless of department or specialist field attends a 40 minute session on Infection Control. This session covers areas such as standard precautions, basic hand washing techniques and needle stick prevention. Time is also spent discussing the most common infections found in the Mater Private Hospital and outlining the general infection control precautions for each. MRSA, Enteric infections, and blood borne infections are covered.
All Staff are also updated annually at 30 to 60 minute update sessions on infection control. These sessions cover hand hygiene and standard precautions as well as providing staff will information on specific infection control issues such as wound care as well as providing an opportunity to discuss MRSA rates and other HCAI rates such as wound infection rates. Feedback on interventions and quality improvement initiatives taken the previous year is also provided.
Staff awareness programmes are also organised in liaison with the quality department. The programmes generally run from 8am –8pm and tea/coffee and cakes are provided during the day to encourage staff to attend. The day provides the Infection Control Nurse with another means of informing staff of results of audits and surveillance. Also included in the day are presentations of any new or updated guidelines. A quiz with questions targeted to re-iterate important issues practice changes is also carried out during the day.
Other initiatives include hand hygiene week, and education sessions in relevant areas when policy updates or new guidelines are introduced and when audit shows a specific area of weakness that requires an increased awareness.
The Intranet has an infection control web page where staff can access guidelines and education session notes directly. This web site also provides direct access to the National Disease Surveillance Centre web site.
Staff education sessions are also run at ward and department level throughout the year when guidelines are updated or new guidelines introduced. These are placed on the intranet so that staff can view them if they wish.
The hospital news letter is also utilized as a means of staff education on Infection Control issues.
The Infection Control Nurse encourages participation of all staff in the Infection Control Programme. Contract cleaning staff, portering staff, catering staff and all ancillary staff are communicated with regularly and included in all education initiatives. Staff feedback is encouraged to ensure Infection Control is considered an active and integrated part of practice.
Annual review
An annual review of results from surveillance and audits takes place involving the Infection Control committee. Quality initiatives from the previous year are examined and any further actions required agreed. New guidelines and research related to practice are reviewed. These discussions then form the basis for the following year’s targets and practice changes. These are agreed with the Infection Control Committee and forwarded to QUEST for inclusion in the hospital quality plan.
