Isolation and infectious diseases policy - Hampshire Hospitals NHS ...

Winchester & Eastleigh Healthcare NHS Trust
Policy for Isolation and Infectious Diseases Policy
E-learning for infection prevention and control is an acceptable alternative
on alternate years once face to face induction is completed. E-learning is
accompanied by certification which can be used in evidence at appraisal.
Completion of the Infection Prevention and Control booklet can also be
carried out on alternate years, available from the Education & Training
Department.
16 MONITORING COMPLIANCE WITH THIS POLICY
18
Authorities
It is important to minimize the risk of the spread of infection to and from patients
and staff. This policy outlines the measures, which should be taken to prevent
the spread of infection from patients who are known to be a potential source of
infection.
This will be monitored by:
Monitoring the trends of infections in the Trust by analyzing alert
organism figures.
Ensuring when isolation of infected patients cannot occur that clinical
incident forms are filled in.
Site coordinators collecting data when patients cannot be isolated.
Monitor that the correct signage and isolation guidelines are adhered to
by all staff by undertaking ad hoc observational audits during ward
visits.
Ensuring that non compliances to policy are challenged appropriately
by any member of staff and not left. Any complaints must not be
discriminated against.
Compliance with this policy should be audited regularly by bed
managers or divisions and noncompliance reported divisionally and to
the Infection Prevention and Control Committee. The IPCNs will
facilitate the audit process if required.
There is a regular programme of audits, led by the DIPC and coordinated
by the IPCT, which are reported to the Infection Prevention
and Control Committee (IPCC), e.g. Hand Hygiene, use of Isolation
facilities, infection control policy compliance, High Impact Interventions.
Divisional audits are reported via the divisions to the IPCC and
Divisional Governance Committees
Alert organism surveillance and trends are reported to the IPCC
Mandatory surveillance is reported to the IPCC, divisions and Trust
Board.
Serious Incidents Requiring Investigation (Infection) are discussed at
Document Control Information
Author:
Sponsor:
Date:
Dr Kordo Saeed
microbiologist
Sue Dailly Lead Nurse
Infection Prevention and
Control
Paula Shobbrook Director of
Infection Prevention and
Control
01/08/11
Type:
Scope:
Reference:
Issue No:
Status:
Policy
Major
CP022 (IC 04)
4
Published