Standard 3:
Health Care Associated Infection
Criterion
1. Governance and systems for infection
prevention, control and surveillance
2. Infection prevention and control strategies
3. Managing patients with infections or
colonisation
4. Antimicrobial stewardship
5. Cleaning, disinfection and sterilisation
6. Communicating with patients and carers
Standard 3:
Health Care Associated Infection
The intention of this Standard is to:
• Prevent patients from acquiring preventable healthcare
associated infections and effectively manage infections
when they occur by using evidence-based strategies.
• Applied in conjunction with
– Standard 1, ‘Governance for Safety and Quality in Health Service
Organisations’ and
– Standard 2, ‘Partnering with Consumers’
What is important - getting started
• Read the whole of Standard 3, the SQIG and the
workbook first
• Identify what is working well and will provide the
evidence to meet the intent of the action, item or criterion
• Conduct a gap analysis or baseline review looking at
how governance works in your organisation and if it is
effective when addressing the risks
• Complete a risk assessment for the areas where further
work needs to be completed to meet the intent of the
standard
• Prioritise action based on the findings of the gap analysis
and risk assessment so they reflect the local context
Why have a Standard about
preventing infection?
• About half healthcare associated infections are thought to be
preventable
• HAI is the most common complication affecting patients in hospital
• Infections increase morbidity, mortality, pain & suffering
• Cost to patients, hospital staff and the health system
• Mechanisms exist to reduce the rate of infections caused by
healthcare.
• No single cause of infection, there is no single solution to
preventing infections
• Successful infection prevention and control requires a range of
strategies across the healthcare system
3.6 Immunisation
• A workforce immunisation program that
complies with current national guidelines.
Questions
– How do we balance the individual staff right of choice compared with
the National Health and Medical Research Council (NH&MRC)
immunisation guideline and the Australian Commission on Safety
and Quality in Health Care (ACSQHC) new National Standards in
respect to staff immunisation?
– Will specialty hospitals such as a maternity hospital be required to
attain greater immunisation requirements due to the NH&MRC
immunisation guideline regarding Pertussis?
– Is it the intention of the ACSQHC for all new staff employed to attain
compliance to staff immunisation guidelines?
– How do we deal with existing staff who have been employed prior to
implementation of the new National Standards with regards to staff
immunisation?
– What information needs to be provided by the hospital to ensure we
attain the minimum requires of the new National Standards
regarding staff immunisation?
Actions that can be considered
• Jurisdictional requirements need to be met
• Risks to the organisation will be
determined by the services provided
• Responsibilities of training and contractor
organisations
• Risk assessment for organisation; policy;
data on staff vaccinated, plan for
maintaining compliance;
8.18.1 Reuse of medical devices
Action is taken to maximise the coverage of
the relevant workforce trained in a
competency-based program to
decontaminate reusable medical devices
Questions
• Who is the relevant workforce?
• Does this mean CSSD staff?
• Or are we talking to the level of nursing
staff wiping down a blood pressure cuff
requiring competency based training?
• Competency based training packages – is
“standard and transmission based
precautions” enough for clinical staff?
Actions that can be considered
• This will be determined locally, based on activities
undertaken and being performed
• Training may be additional to SSD staff as there may be
reusable devices utilised outside the theatres that will
require the staff to decontaminate then e.g.
nasoendoscopes in an ENT clinic
• Training in standard and transmission based precautions
is not sufficient in these situations and requires local
assessment to determine what training will maintain
safety of the workforce, patient and equipment. This may
include proprietary training by suppliers, network/district
training or online training resources that are competency
based.
3.10 Aseptic Technique
• Developing and implementing protocols for
Aseptic Technique
Questions
• Who assess surgical procedures?
• Is this aseptic technique throughout the
whole procedure?
• Does this come under peer review of college
approval to practice?
• Do we have to assess the doctors for aseptic
technique? (IV insertion) We only have
visiting medical officers.
Actions that can be considered
• The governance structure will determine how aseptic
technique will be assessed as a risk in an organisation
depending on what procedures are performed where
aseptic technique is required.
• Consultation and review of contractual agreements will
assist to determine how governance will respond.
• Consider where the risks are in your organisation and
prioritise accordingly
• Consider the ACORN standards to use in the operating
theatre to assess technique
• Peer review may assist but would need to be reviewed to
determine how it is undertaken for approval to practice in
your organisation
Antimicrobial stewardship
Safe and appropriate antimicrobial prescribing is a
goal of the clinical governance system
• A program is in place
• Access to current endorsed therapeutic
guidelines on antibiotic usage
• Monitoring of usage and resistance is
undertaken
• Action is taken to improve effectiveness of AMS
Questions
• As a private facility where our Doctors are
our consumers and not directly employed
by us, how can we tell them which
antibiotics they are and aren’t allowed to
prescribe.
• Has AMS been pushed through the AMA
and associated colleges?
• How do we change their prescribing
habits?
Getting started
Helpful hints
• Assess the current situation
– Risk
– Current governance arrangements
– Current policies, processes and resources
– Data currently collected
– Any audit results
– Current resistance patterns, infections
• Awareness raising
– Share results
• Contractual arrangements co-ordinated by governance
systems for medical officers and other contracted services
• Identify what you are currently doing
• Look for other areas that support AMS
• Engage clinicians in the processes
• Start small and look for champions
• Utilise the resources available
• Present results and surveillance data
• Feedback
• Utilise the SQIG and the other resources available
12-18 November 2012 Antibiotic Awareness Week