Public hospital infection control program

Page contents: Overview | Infection Control and Cleaning reporting requirements | Cleaning | Infection Control | Hand Hygiene | Terms of Reference for Victorian Advisory Committee on Infection

Overview

The effective prevention, monitoring and control of infections are an integral part of the quality and safety and clinical risk management operations of any health service. While not all health care acquired infections can be prevented, the department and health services can ensure that systems are in place to minimise their occurance.

The key components for the prevention and control of health care infections are:

• the implementation and monitoring of a sustainable hand hygiene program
• the availability of an alcohol and chlorhexidine hand rub in all ward areas attached (or near) each patient bed and at the entrance to wards, lifts and hospital entrances
• to improve hospital cleaning standards in accordance with the Victorian Cleaning Standards
• improving adherence to staff infection control guidelines in accordance with departmental and Communicable Diseases Network Australia (CDNA) Infection Control Guidelines.
• participation of all Victorian Health Services in the VICNISS Hospital Acquired Infection Surveillance System according to the Type 1 and Type 2 performance indicators
• monitoring and reducing the emergence of antibiotic resistant organisms and vaccine preventable diseases, in accordance with both CDNA and relevant departmental guidelines
• active surveillance for methicillin resistant Stapylococcus auerus
• the judicious use of antibiotics
• to enhance the testing capacity for resistant microorganisms
• to improve the uptake of health care worker vaccination coverage for vaccine preventable diseases

Infection Control and Cleaning reporting requirements

The Victorian Public Health Services, Performance and Accountability Framework is one of the mechanisms used by the Department of Human Services to formally monitor health service performance. From July 2007 the Cleaning Standards and VICNISS participation have been included as measurements for the – Quality, Key Performance Indicators.

Cleaning

Cleaning standards aim to improve quality health care provision by reducing the burden of pathogenic organisms, and ensuring that all risks involving cleaning are identified and managed in an appropriate manner, irrespective of cleaning service provider arrangements. The standards are focused on the outcome or output sought, rather than the method by which it is achieved.

The cleaning key performance indicator aims to maintain the hospitals standard of cleanliness according to the Victorian Cleaning Standards.

• The indicator will be expressed as achieved/not achieved.
• The assessments will be based on both internal and external audit results submitted to the department.
• Reporting of cleaning standard results is mandatory for all health services.

Infection Control

Research has demonstrated that up to one third of hospital acquired infections can be prevented with high intensity hospital acquired infection surveillance and control programs (Haley et al. 1985).

The infection control data compliance key performance indicators aim to improve the quality of infection control data reported to the Victorian Hospital Acquired Infection Surveillance System (VICNISS) Coordinating Centre.

• The VICNISS performance indicators are set out in the Surveillance Hospital Participation documents.
• These outline the defined set of surveillance activities and data quality indicators that hospitals are required to perform and achieve.
• A public health service’s performance will be analysed quarterly by the VICNISS Coordinating Centre.
• The VICNISS Coordinating Centre will provide a report to the Quality and Safety Branch of the department detailing each hospital’s performance.
• It is mandatory for all health services to participate according to the VICNISS Type 1 and Type 2 performance indicators

Hand Hygiene

The major transmission route for multi-resistant organisms (MROs) in health care facilities is by direct contact via the hands of health care workers or possibly indirectly via contaminated equipment that is not cleaned between patients. Therefore, there has been resurgence in the promotion of hand hygiene as an effective method of preventing transmission of infections.

In 2004, the Victorian Quality Council initiated and funded the Victorian Hand Hygiene Project as a pilot in six Victorian public hospitals to reduce the incidence of hospital acquired infections. The project actively promoted the use of alcohol hand rubs for all health care workers, carried out observational studies to monitor hand hygiene compliance, provided feedback to staff, and monitored methicillin resistant Staphylococcus aureus (MRSA) rates. The VQC project was then successfully rolled out during 2005–06 to all public hospitals in Victoria. From July 2007 the Department of Human Services has continued the Victorian Quality Council (VQC) hand hygiene project.

All health services are required to:

• Continue staff hand hygiene education
• Collect hand hygiene data compliance
• Provide hand hygiene compliance and MRSA data to the hand hygiene coordinating centre
• Allocate hand hygiene products in all wards and clinical areas of the hospital (including attached to or near each patient bed)
• Make hand hygiene products available at the lifts, hospital entrances and wards
• Achieve an overall mean hand hygiene compliance of 55% in all audited areas by June 2008
• Report hand hygiene compliance rates in the hospitals Quality of Care reports
• Make the program sustainable at a local level

Terms of Reference for Victorian Advisory Committee on Infection Control

The Victorian Advisory Committee on Infection Control (VACIC) is established to advise the Department of Human Services (the Department), through the Statewide Quality Branch, on strategic directions and policy development with respect to healthcare associated infection control and prevention.  Initiatives of the committee, where appropriate, should be evidence based and aligned with national or state based evidence and activities.

1 Objectives
The Advisory Committee will contribute to the prevention, detection and control of infections by:

1.1 Recommending to the Department of Human Services the need for policies, standards of practice and operational measures to prevent and control community and healthcare associated infections.

1.2 Monitoring local, national and international initiatives responding to emerging issues that can be adopted or used within Victoria.

1.3 Providing advice and guidance to services providing health care and those providing education on infection control.

1.4 Convening ad hoc working groups to advise the Committee on prevention, detection and control of infection issues related to health care.

1.5 Analysing information referred to the Committee from the Clinical Risk Management Reference Group on system infection control issues, adverse or sentinel events and providing advice on strategies for system improvement.

1.6 Report as required to the Minister of Health through the Director, Statewide Quality Branch.

2.1     Membership will include representatives from the following:

• Australian Society for Infectious Diseases;
• Australian Society for Microbiology;
• Directors of Nursing Group;
• Institute of Hospital Engineering, Australia;
• Statewide Quality Branch;
• Microbiological Diagnostic Unit;
• Aged Care sector;
• Private Hospitals’ Advisory Group;
• Private Hospitals Unit, Department of Human Services;
• Public Health, Department of Human Services;
• Royal Australasian College of Surgeons;
• Sterilization Research and Advisory Council of Australia;
• VICNISS;
• Hospital Chief Executive Officers Group; and
• Victorian Infection Control Professional Association – Metropolitan and Rural.

2.2 Membership
The term of appointment will be two years.

That generally the maximum number of terms will be no greater than three (consecutively).

If a member is an apology and/or does not attend for more than three consecutive meetings in one calendar year, without advising the Chair or secretariat, the membership will discontinue.

The Director of the Statewide Quality Branch will appoint the Chair.

2.3 Proxies
The secretariat must be notified prior to the meeting if a proxy is to attend a committee meeting.

3 Communication

• All communication will be received through the secretariat of VACIC; and
• All correspondence received will be formally acknowledged within five working days of receipt; this will be followed up with a letter regarding the outcomes.

4 Reporting

4.1 The Chair will be responsible to, and communicate through the Director, Statewide Quality Branch, Rural and Regional Health and Aged Care Services.

4.2 The VACIC will report when required to the Minister for Health and the Department of Human Services.

5 Governance of VACIC

5.1 The Governance Group to VACIC, a subcommittee consisting of representatives of the Public Health and Statewide Quality Branches:

5.1.1   will meet between meetings to ensure the work of the Committee continues;
5.1.2   will review the outstanding items on the business list, and report on their status; and
5.1.3   will scope and address the issues, and propose an action plan to address them.

6 Projects

6.1  Reports on key initiatives or projects from the Statewide Quality Branch and the Victorian Quality Council, where they align with VACIC’s objectives and interest will be given consideration by the Committee.

7 Meeting Frequency

7.1 A minimum of six meetings will be held each year, or as otherwise arranged, according to specific requirements as may occur from time to time; and Meetings will not be held in January.

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 VICNISS Hospital Acquired Infection Surveillance Annual Report 2009 - 2010

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