Part 5: Relationships Between Infection Control and the Rest of the Hospital Service

Management of Hospital-acquired Infection.

Introduction

5.1
Infection control is a hospital-wide function. Everyone working in a hospital has a part to play in making certain that infection control standards are applied. Ensuring that this happens should be a concern of a range of managers throughout the hospital, with overall responsibility resting with the General Manager.

5.2
Unlike most other clinical staff, infection control practitioners do not work in single hospital wards or units. Instead, their activities cover all parts of a hospital (or group of hospitals), and all aspects of day-to-day activities. Because their work has an impact on the work of many other staff – and in many cases needs to influence the way their work is done – it is important that the functions and responsibilities of infection control practitioners are well recognised and understood.

5.3
Equally, infection control staff do not work within a clinical hierarchy in the same way as other nurses or doctors. In order to fulfil their infection control responsibilities, staff in the infection control team must have the authority to examine policies, procedures, and practices throughout the hospital. They must be able to scrutinise the practices of even the most senior medical consultants – otherwise there will be gaps in the management of infection control that will put the hospital service at risk.

5.4
These key features have two important implications for the relationships between infection control staff and other staff in the hospital service. Infection control staff:

  • must have the necessary authority and recognition within the hospital service to enable them to do their job properly; and
  • need to communicate effectively and establish credibility with staff and managers at all levels, so that their guidance is readily accepted and applied.

5.5
In this part we examine:

  • the role and organisation of infection control committees;
  • use of nominated infection control representatives in parts of the hospital (such as wards);
  • links between infection control and hospital services’ overall management of risk;
  • how infection control staff work together with occupational health and laboratory services94;
  • links with Medical Officers of Health (who are responsible for controlling the impact and spread of communicable diseases in the community); and
  • getting the hospital environment right for infection control, so that the risks of hospital-acquired infection are minimised.

Role and Organisation of the Infection Control Committee

5.6
The infection control committee plays a vital role in supporting the infection control team and overseeing the co-ordination of infection control matters throughout the hospital service. In extreme circumstances, the role of infection control practitioners may lead to confrontation with colleagues – for example, where a colleague refuses to accept that they need to improve their hygiene practice. Infection control staff need to be:

  • strongly supported within the hospital structure;
  • able to draw on the expertise of a wide range of disciplines; and
  • able to refer to a body of objective research and knowledge in order to give practical authoritative advice and promote credible improvements.

5.7
The infection control committee should include representation from relevant disciplines within the hospital service. The purposes of the infection control committee are to:

  • assist in the establishment of the infection control programme, and approve the programme in consultation with other key clinical staff or departments;
  • ensure that the necessary resources are available to implement the programme, and assist in its implementation where required by providing support to members of the infection control team;
  • monitor and review the programme; and
  • report regularly to hospital management on risks to patient care, systems failures, infection outbreaks, and audit results.

Survey Responses on the Organisation of Infection Control Committees

5.8
We asked:

  • how often the committee met, and who were its members; and
  • how often members attended meetings of the committee.

5.9
All hospital services had an infection control committee. Most committees met at least monthly.95

5.10
Among their members, the committees most commonly included infection control practitioners and doctors, and representatives from the hospital laboratory (see Figure 9 on the next page). Often, the Medical Officer of Health was a committee member, thereby potentially providing a useful link between the hospital service and the community on communicable diseases. In smaller hospital services, often the hospital’s General Manager or representative was a committee member, reflecting differences in structure between larger and smaller hospital services.

Figure 9
Who Are Members of the Infection Control Committee?96

Does the Committee have a member in this staff category? Yes No
Infection Control Practitioner(s)* 20 0
Doctor(s) 20 1
Microbiology (i.e. laboratory) representative 20 1
Medical Officer of Health 17 4
Director of Nursing 13 8
Risk or Quality Improvement Manager* 12 8
Occupational Health Nurse(s)* 12 8
Pharmacist 11 10
Medical Director 10 11
Services manager(s) 10 11
Representative from other hospitals covered by Committee 7 14
Hospital General Manager or representative 6 15
Community representative 5 16
Maori Health representative* 2 18

* In each case one respondent did not answer this part of the question.

5.11
Hospital staff are exposed to the risk of acquiring infection through various forms of contact with patients, such as blood and body-fluids. However, only 12 committees included an occupational health nurse, making it less likely that staff health and welfare matters – such as staff exposure to infection – would come to the attention of the committee. Without occupational health service representation, the committee would also be less likely to identify and consider the infection control policies and practices that might promote the health and welfare of staff.

"... Representation at these [Infection Control Committee] meetings continues to be a problem …"

5.12
Hospital pharmacists are a key professional group whose work brings them into contact with staff and patients throughout the hospital service. They are responsible for promoting prescribing practices that minimise the infection risks associated with organisms that become resistant to antibiotics. Their knowledge and experience is therefore essential to the infection control committee’s work. However, only 11 of the respondents had a pharmacist as a member of the committee.

5.13
Most hospital services reported that infection control practitioners, laboratory representatives, and pharmacists (where they were members of the committee) always attended the meetings of the infection control committee.97

5.14
However, only a little more than half of committee members in other staff categories always attended the meetings.98 Only one-third of respondents reported that three key categories of staff – Medical Officers of Health, risk managers, and occupational health nurses99 – always attended the meetings.

Survey Responses on Meeting Minutes and Annual Reports

5.15
We asked whether minutes were made of infection control committee meetings, whether the infection control committee produced an annual report, and if so who received these documents.

5.16
All respondents reported that minutes were made of infection control committee meetings.100 In all but one hospital service the members of infection control committees received copies of the minutes (see Figure 10 on the next page).

Figure 10
Who Receives the Minutes of Infection Control Committee Meetings?101


 Receives Does not receive
Members of the Infection Control Committee 20 1
Hospital General Manager 15 6
Director of Nursing 15 6
Quality or Risk Management Committee 14 7
Medical Director 13 8
Clinical Governance Committee or equivalent* 10 10

* One respondent did not answer this part of the question.

5.17
Managers or groups with responsibility for oversight of clinical risk and practice within the hospital service should receive minutes of infection control meetings. Such groups would include the quality or risk management committee and the clinical governance committee (or equivalent). As shown in Figure 10, two-thirds of quality or risk management committees received the minutes, compared with only half of the clinical governance committees.

5.18
Annual reports on infection control can serve a number of purposes by:

  • summarising data on, and analysis of, rates and types of hospita-lacquired infection over time;
  • documenting the causes of outbreaks that occurred over the period, how they were managed, and lessons learned from the experience;
  • reporting on the results of monitoring and audit of compliance with infection control policies; and
  • outlining infection control strategies for the coming year to address identified concerns.

5.19
Seven respondents told us that their infection control committee produced an annual report.102 All but one sent the annual report to the hospital general manager, the medical director, and members of the infection control committee. Most also provided the report to the quality or risk management committee (five of the seven) and to the director of nursing (four of the seven). However, only two provided the report to the clinical governance committee (or its equivalent).103

5.20
Four of the six with tertiary hospitals (where the risks of hospitalacquired infection are highest) produced comprehensive annual reports. These reports:

  • helped to raise the profile of the infection control service and its staff;
  • provided a useful summary for managers and clinicians; and
  • served as a basis for planning into the next period.

5.21
The annual report that one infection control team sent to us contained the following information on performance and risk that hospital managers and (potentially) the Board of the DHB would find valuable:

  • rates for both hospital-acquired bloodstream and surgical wound infections had declined on average by 20% compared with the previous year;
  • the circumstances surrounding the incidence of infection were analysed and reasons suggested for changes in rates for specific infection types;
  • micro-organisms discovered through laboratory examination were analysed for comparison with the previous year – analysis showed an increase in the prevalence of Clostridium difficile isolates, an organism associated with cross-infection and the prescribing of particular antibiotics;
  • an estimate of the direct and indirect costs associated with treating types of hospital-acquired infection for different patient groups;
  • action plans for changes to practices that had contributed to increases in infection rates (such as practices associated with the insertion and maintenance of intravenous catheters and antibiotic prescribing); and
  • a programme to address concerns – such as rising prevalence of multi-drug-resistant organisms – and to manage risk factors (including hospital hygiene, cleaning, and the maintenance of hospital equipment).

Conclusions

5.22
In most hospital services, membership of the infection control committee reflected the range of infection control interests throughout the organisation.

5.23
However, eight of the committees had no occupational health representation, making it less likely that committee discussions would have adequate regard to policies and practices that might promote the health and welfare of staff. Similarly, we were concerned that almost half had no pharmacy representative – given pharmacists’ key role in promoting prescribing practices that minimise the risk of antibiotic resistance.

5.24
With some members absent from the committee meetings, discussion of infection control matters may not take account of all relevant views and considerations, and valuable knowledge and experience may not be shared. Irregular attendance may also reflect a lack of proper commitment to, and support for, infection control within the hospital service.

5.25
Communication is an important function of any infection control committee, but few committees reported on their year’s activities. Those that did so distributed the reports widely to hospital managers and others, and the reports we saw were informative – providing useful summaries of performance and plans.

Recommendation 20
Hospital services should ensure that:
• their infection control committee includes representation from occupational health and the hospital pharmacy; and
• members attend committee meetings on a regular basis, to help ensure that discussions draw on the full range of views and experience.
Recommendation 21
Infection control committees should consider producing an annual report of their activities and plans, to help maintain the profile of the infection control service and to keep staff and managers informed of infection control issues.

Use of Infection Control Representatives

5.26
In some hospitals, clinical staff are nominated as infection control representatives. They are usually nurses who have been given additional training in promoting and advising on good infection control practice. These representatives complement, but should not take the place of, infection control practitioners.

Survey Responses on Infection Control Representatives

5.27
We asked whether hospital services had infection control representatives and how successfully they were used.

5.28
Two-thirds had infection control representatives who mainly worked in ward areas.104 These representatives had an important role in raising staff awareness of infection control matters, sharing knowledge with peers, and helping with surveillance and early detection of outbreaks.

"…[Infection control representatives’] input into our policies/procedures assists us in making them ‘workable’ and ‘user friendly’ so implementation is easier …"

5.29
To be successful, a network of infection control representatives needs to be actively managed and promoted. From the survey responses105 and discussions during our visits, we noted a number of barriers to making best use of representatives:

  • where staff turnover is high, it is difficult to maintain continuity of experience and knowledge among representatives;
  • the full value of training new representatives may not be gained when they leave their job after only a short time;
  • pressure of work can leave the representatives with little time for infection control activities. There may be few opportunities to attend meetings and training, and limited access to resources and management support; and
  • little recognition may be given to a role that is voluntary and involves extra responsibility.

5.30
One hospital that we visited had drawn up a detailed description of infection control representatives’ role and responsibilities. The description included reference to a range of tasks – attending meetings, helping to resolve infection control issues, introducing infection control initiatives in their area, participating in quality improvement teams, and consulting with the infection control team.

"… We have some excellent reps. There is difficulty in getting representatives for all wards/units as it is a voluntary position … some units struggle to find volunteers …"

Conclusions

5.31
Infection control representatives can play an important part in raising staff awareness of infection control and in promoting good clinical practice. Two-thirds of DHB hospitals had infection control representatives, but there were barriers to making best use of them. Clearly defining the role and responsibilities of infection control representatives is an essential first step towards ensuring that they are used well and identifying what support they need.

Recommendation 22
Hospital services should consider the merits of putting in place a network of infection control representatives (or review the effectiveness of the existing network), having regard to both potential benefits and the obstacles to making best use of the network.

Infection Control and the Management of Risk

5.32
The Standard (see paragraph 2.27 on page 46) requires hospital services to give priority to managing infection risk. Infection control should be a key component of any hospital risk management programme.

Survey Responses on the Links between Infection Control and Risk Management

5.33
We asked hospital services whether their infection control programme was linked to the quality improvement or risk management programme. Four (including two of the six that have tertiary hospitals) reported that they made no link between the infection control and risk management programmes.106

"… The Infection Control programme is incorporated into the surgical service plan and linked to the Risk Management programme through the Risk Management Committee …"

5.34
Figure 11 (on the next page) contains extracts from the risk register of a large DHB that we visited. In this example, ‘high risk’ is intended to mean that senior management attention is required, and ‘low risk’ that management by routine procedures is sufficient.107

Figure 11
Illustration of Infection Control Risks Extracted from the Risk Register of One DHB

Description of Risk How could this happen? What can we do to prevent it? How high is the risk?
Ongoing exposure of staff and patients to tuberculosis. No formal contact-tracing procedures for staff.

No testing for new staff.		 Address through occupational safety and health programme. High
Emergence of multi-resistant organisms. Indiscriminate prescribing of antibiotics. Educate doctors.

Prepare guidance sheet.		 High
Lack of formalised staff health programme. Service not managed by the DHB.

Crisis management on an as-needs basis provided inappropriately by infection control staff, which sacrifices other infection control activities.		 Recommendation documented by the Infection Control Committee to the Clinical Practice Committee for an Occupational Health and Safety programme. High
Chemical/biological indicators not in use in autoclaves used for sterilisation. Inadequate staff training. Chemical/ biological indicators not available. Lack of orientation and staff awareness. Education/orientation at departmental level. Low
Over- or incorrect packing of autoclave used for sterilisation. Inadequate staff training. Chemical/ biological indicators not available. Lack of orientation and staff awareness. Education/orientation at departmental level. Low

5.35
One smaller hospital service had drawn up a set of infection control indicators that were referenced to its Quality and Risk Management Plan, with results reported to the DHB. The indicators used clear definitions to describe hospital-acquired infection, making it possible to measure data collected through the infection control database and incident reports. The Plan also contained a schedule of infection control audits to be undertaken, outlining:

  • the scope of the audit (such as an audit of hand hygiene or of the food services area);
  • the audit method to be followed;
  • the performance target to be met; and
  • the source of audit data.

5.36
Reporting of infection control matters should also form part of a hospital service’s reporting of organisational risk. One infection control committee was reporting to the risk committee, along with other clinical committees, including the Drug and Therapeutic Committee. This reporting facilitated a co-ordinated approach to different areas of hospital practice related to infection control – such as antibiotic prescribing, and re-use of medical items.

Conclusions

5.37
Not all hospital services were taking a co-ordinated approach to risk assessment that encompassed infection control.

Recommendation 23
Hospital services should use a risk-based approach for their infection control planning, and integrate infection control into their quality assurance and risk management programmes.

Working with Occupational Health Services

5.38
Protecting the health, safety, and welfare of staff is consistent with the statutory good-employer obligations of DHBs, and with their responsibilities under the Health and Safety in Employment Act 1992.

5.39
The infection control programme should encompass, or be closely related to, employee health programmes designed to:

  • protect staff from exposure to infection; and
  • detect and monitor staff who may be colonised108 or infected with a communicable disease posing a risk to patients, their colleagues, and others in the hospital (paragraphs 7.14-7.20 on pages 156-158 examine screening of staff to identify infection).

Survey Responses on Occupational Health Services

5.40
Occupational health and infection control services each have their own distinct, but closely related, focus. We asked about the relationship between occupational health and infection control services, and how well the two groups worked together.

"… Offices located beside each other, in the same department. Daily dialogue occurs, especially around staff safety, needle-stick injuries etc …"

5.41
Nineteen hospital services reported that occupational health and infection control services were provided by separate groups.109 Most also reported that this arrangement worked well and some gave the following reasons:110

  • staff had complementary knowledge, which helped to ensure that they communicated effectively and worked well together;
  • roles and responsibilities were clearly defined;
  • the arrangements worked best in hospital services that provided adequate resources for both occupational health and infection control;
  • the services co-ordinated their efforts on matters of common concern (such as pre-employment screening of staff, tracing staff for patient contact, and screening staff for infection); and
  • they provided cover for staff in periods of leave.

5.42
One hospital service noted that the relationship worked well because the occupational health nurse sat on the infection control committee, and so was well aware of staff issues with infection control implications. The infection control practitioner and the occupational health nurse met to discuss staff issues of mutual interest, and the infection control team was able to provide cover for matters relating to staff exposure to blood and body-fluids, and screening new staff. Occupational health and infection control staff together screened staff in the event of an outbreak, and jointly followed up staff who had been exposed to an infectious disease.

5.43
Responsible occupational health practice requires hospital managers to make staff aware of precautions they can take to avoid or mitigate health risks from exposure to infection. It should make certain that all possible measures are in place to ensure safe working conditions. Concerns about staff welfare were raised in the course of our hospital visits and in survey comments. For example, in one hospital we visited, the occupational health service had a limited role in relation to infection control. As a result, the occupational health service was poorly placed to follow up at-risk staff by taking the necessary actions to improve staff education and address hazards in the hospital environment.

5.44
The same hospital’s annual blood and body-fluid exposure report showed that staff had reported more than 300 incidents over the period. Most of these incidents were not entirely avoidable given the nature of their work. However, there were other measures that the hospital could have taken to reduce the level of risk. For example, the hospital was not:

  • screening new staff for infectious agents (such as Hepatitis B) other than MRSA; or
  • offering staff free vaccinations as an incentive to obtain protection.

5.45
Blood test results from staff after the 300 incidents showed that more than 20% of staff were not immune to Hepatitis B. Blood tests of the patients involved showed that 2% were infected with Hepatitis B, 8% were infected with Hepatitis C, and one patient was HIV positive.

Conclusions

5.46
Occupational health and infection control services were almost always delivered separately. In most hospital services, the two service groups were well co-ordinated and were collaborating in a positive way to provide a safe environment for patients and staff. However, concerns were also expressed – including some from staff in larger hospitals – about the delivery of infection control services relating to staff health.

Recommendation 24
Hospital services should ensure that the activities of occupational health and infection control are well co-ordinated, and that the two groups collaborate in the interests of patient and staff safety.

Working with Laboratory Services

5.47
The working relationship between the infection control team and the hospital’s laboratory is very important. Information from laboratory tests enables hospitals to identify infectious diseases, determine the prevalence of infectious organisms, and establish whether those organisms are susceptible to antibiotics and other drugs. Infection control teams and laboratory staff should work as a team to identify and control outbreaks when they occur.

Survey Responses on Laboratory Services

5.48
Members of the infection control team should have frequent contact with laboratory staff and the two professional service groups should freely share appropriate information. We asked whether:

  • the hospital laboratory was conveniently located for infection control purposes;
  • the organisation and scope of laboratory services were clear; and
  • the infection control team had ready access to laboratory services at all times.

5.49
Finally, we asked infection control teams to rate the performance of the hospital laboratory.

5.50
Nineteen infection control teams considered the laboratory to be very or fairly conveniently located for their purposes.111 Staff from one of the other two teams had to make a 20-minute journey to the laboratory every morning. In the other case, the hospital site was very large and access to laboratory services was difficult.112

5.51
Most infection control teams were confident that they had a full understanding of the organisation of the laboratory and the scope of the services provided.113

5.52
Laboratories must be able to respond quickly to possible outbreaks by carrying out diagnostic tests to enable precautionary measures to be taken. Nearly all teams reported that they had urgent access to laboratory services at all times.114 One small hospital service noted that access was limited outside normal working hours, with only two staff available after hours or on public holidays.

"... very professionally managed, high level of quality assurance, able to respond to requests rapidly, experienced staff, good equipment, easily accessible, quick response to requested tests, 24-hour service …"

5.53
Twenty infection control teams assessed the laboratory service as effective or very effective.115 Among the reasons given for the assessment were that:116

  • the infection control team and laboratory personnel worked well together;
  • the laboratory service was accredited, and so met independent quality standards;
  • the laboratory provided highquality testing, and prompt, reliable results, and could carry out urgent tests after hours; and
  • the laboratory technologist sat on the infection control committee, which helped to keep infection control staff informed about matters such as antibiotic-resistant organisms and notifiable diseases.

5.54
The one infection control team that was less satisfied with the laboratory service cited inadequate arrangements for supervision by a medical microbiologist – who was based about 800 kilometres away and visited only twice a year. However, the team described the technical capability of the laboratory as “excellent”.

Conclusions

5.55
Infection control teams had positive working relationships with laboratory staff, with generally good access and evidence of constructive collaboration on infection control matters of common interest.

Links with Medical Officers of Health

5.56
Infectious diseases can pass between the hospital and the community – people may bring infections into a hospital, and patients may take infections into the community when they are discharged. Hospital-acquired infection is therefore a safety issue for both hospitals and the community.

5.57
Twenty-four Medical Officers of Health are employed by and based in DHBs’ public health care services.117 The Health Act 1956 gives them wide-ranging powers to deal with national and local outbreaks of infectious disease that have implications for the public. Associated activities include:

  • identifying risks and drawing up contingency plans to respond to outbreaks;
  • investigating suspected incidents, cases, and outbreaks; and
  • taking measures to control the spread of disease.

5.58
Most infection control teams considered that the Medical Officer of Health should ideally have a key role in infection control within the hospital service, and agreed that the Officer should118:

  • be a member of the infection control committee;
  • work with the infection control team in managing outbreaks;
  • provide epidemiological119 advice;
  • ensure that relevant hospital staff understand the infection risks in the community and the different approaches to controlling them; and
  • contribute to the flow of information between the hospital service and public health officials.
"… The Medical Officer of Health is a member of the Infection Control Team and is actively included in infection control policies and issues …"

5.59
Most DHBs did not make full use of Medical Officers of Health for these purposes.

5.60
The Health Act 1956 specifies those diseases that must be notified to Medical Officers of Health. These notifiable diseases do not include most infections acquired in hospitals, so there is no statutory requirement for hospitals to notify them.

5.61
In our view, there are still good reasons to involve Medical Officers of Health in the event of any outbreak of a hospital-acquired infection. In their statutory role, Medical Officers of Health gain experience and knowledge in the management of infectious disease outbreaks, and are familiar with methods of tracing sources of infection and controlling its spread. This expertise is available and valuable for hospitals to draw on to prevent and contain hospital-acquired infection.

Survey Responses on Medical Officers of Health

5.62
We asked senior hospital managers if the service agreement between the DHB and the hospital service required the Medical Officer of Health to be notified in the event of a communicable disease outbreak in the hospital.120

5.63
In 14 DHBs, a service agreement or contract required the hospital to notify and seek advice from the Medical Officer of Health in at least some circumstances, but almost all of these DHBs expected their hospitals to notify the Medical Officer of Health only where there was a statutory requirement to do so – reflecting a limited interpretation of the role. In only two DHB hospitals was there a wider requirement to notify the Medical Officer of Health. In those cases the Officer was:

  • notified of non-notifiable disease outbreaks with potential impacts on service delivery or community health (such as MRSA); or
  • consulted informally or approached for advice in their capacity as a member of the infection control committee, or through their involvement in the drawing up of infection control policies.

5.64
Prompt reporting of infectious diseases is vital for effective planning and response, and assists with infectious disease surveillance. A patient’s doctor is responsible for notifying the Medical Officer of Health of notifiable diseases. However, there is a risk that busy medical staff could at times overlook this responsibility.

5.65
In May 1997, the Ministry’s Infectious Diseases Advisory Committee agreed that laboratories should be able to report any notifiable diseasecausing organisms directly to Medical Officers of Health (in addition to reporting them to individual responsible doctors). However, more than five years later, only half of hospital services said that they had put in place arrangements whereby the hospital laboratory reported notifiable diseases directly.121

Conclusions

5.66
Where Medical Officers of Health perform a wide role, they are more likely to act as an effective link between the hospital and the community on public health – including helping to prevent and manage hospitalacquired infection. Infection control teams appreciated the value of Medical Officers of Health carrying out this wide role, but most hospital services were not fully using the Officers in this way.

5.67
Most DHBs required infectious diseases to be notified only as expressly prescribed under the Health Act 1956. In addition, around half of hospital services have continued to rely on individual doctors to report notifiable diseases to the Medical Officer of Health, rather than establish direct reporting by laboratories. Where there is no direct reporting, the risk remains that not all notifiable diseases are being notified.

Recommendation 25
DHBs should specify in their service agreements with hospitals the role of the Medical Officer of Health as a public health link between the hospital and the community on the management of hospital-acquired infection.
Recommendation 26
Hospital services that do not yet have arrangements for their laboratories to report notifiable diseases directly to the Medical Officer of Health should consider the need to put such arrangements in place.

Creating the Right Hospital Environment for Infection Control

5.68
Changes to the hospital environment – such as the purchase of products or equipment, alterations to the building, and/or changes in service contracts – can create new risks of infection for patients and staff. Infection control teams should therefore be consulted when changes are proposed.

5.69
Aspects of the physical design of hospitals that need to be considered in minimising infection include:

  • separation of waste collection and cleaning areas from areas occupied by patients and food preparation facilities;
  • effectiveness of ventilation and lighting;
  • provision of adequate storage to reduce clutter and allow effective cleaning in the ward or department, and good access to the storage area so that it can be cleaned easily and protected from contamination;
  • features of patient accommodation, such as access to hand basins; and
  • provision of single rooms for patients who need to be accommodated separately for the protection of their own and/or others’ health.

5.70
The following paragraphs look at how hospital services are consulting infection control staff about building and equipment changes and reviews of contracts for services such as catering.

Survey Responses on Consultation About Building and Equipment Changes

5.71
We asked whether and how often the infection control team was consulted about the purchase of new equipment or plans for alterations or renovations to hospital buildings.

5.72
Only six hospital services reported that their infection control teams were always consulted to ensure that infection control requirements were considered when new equipment was being purchased.122Without such consultation, the infection control risks associated with new equipment may be overlooked. Other hospital services told us that their teams were sometimes consulted on new equipment, except for one team that was rarely consulted.

5.73
Similarly, only five hospital services reported that their infection control team was always consulted when plans for alterations or renovations to hospital buildings were being discussed.123 All other respondents said that their team was sometimes consulted.

5.74
Building construction, renovation, and demolition release into the air large amounts of dust which may contain fungal spores. Most fungal organisms pose little risk to healthy people, but in sick patients (under medical treatment and with low immunity) such organisms can lead to severe infections.

5.75
In one hospital that we visited, major construction activities were under way, posing risks to patients with low immunity. The infection control team had formed a sub-committee to review the risks and promulgate guidelines to minimise exposure. It had established the following key strategies:

  • Infection control staff should be consulted when construction, renovation, or demolition activities were proposed.
  • Environmental monitoring would be undertaken to identify the need for measures to prevent exposure to dust.
  • The health of at-risk patients would be monitored through periodic testing to detect infection so that, when necessary, early treatment could be initiated.
  • The sub-committee would meet regularly to review its recommendations and monitor compliance.

Survey Responses on Consultation About Catering Contracts

5.76
Nineteen hospital services had catering contracts in place.

5.77
Unhygienic food handling facilities and practices can cause infection to spread rapidly through a hospital. Infection control teams should monitor the preparation, distribution, and storage of food to help ensure safe practice.

5.78
Hospital managers should obtain assurance that any contractor providing a catering service operates a system of checks to ensure that safe food handling practices are consistently followed. In obtaining this assurance, the advice of the infection control team should be sought.

5.79
Therefore, we asked whether the infection control team was involved when the catering contract was reviewed.124 Six hospital services said they always involved their infection control team. However, 10 reported that they never did so. As a result, some hospital services may enter into catering contracts without fully considering infection control requirements.

5.80
Under the Food Hygiene Regulations 1974, local authorities must register all premises involved in the manufacture, preparation, packaging, and storage of food for sale. However, specified premises – including hospitals – are defined as “partially exempted premises” and do not have to be registered.

5.81
Nevertheless, some local authorities inspect hospital kitchens because they judge them to be high-risk. The potential impact of a food-borne infection on vulnerable hospital patients is high, so there is a good case for requiring hospital kitchens to meet the same hygiene standards expected of other catering premises.

Survey Responses on Consultation About Laundry Arrangements

5.82
Soiled or torn linen can expose patients to the risk of infection. Laundry facilities therefore need to be run by appropriately trained staff, equipment needs to be properly maintained, and laundry areas must be kept clean and well ventilated, with a clear separation between dirty and clean linen. Torn linen should be repaired or discarded if it no longer meets requirements.

5.83
We asked whether the infection control team was involved when the laundry contract was reviewed. Seven respondents (just under half of those with contracts)125 said they always involved their infection control team. Four reported that they never did so. As in the case of catering contracts, this lack of involvement may result in contracts being entered and renewed without proper consideration of infection control requirements.

5.84
Accreditation (see paragraph 2.21 on page 44) can prompt improvements in activities that have an impact on the safety of the hospital environment. To achieve accreditation, one hospital service we visited was required to undergo an audit of its laundry service. The infection control team had had long-standing concerns about the quality and safety of the service, which was provided by another DHB. The audit showed that the service did not comply with the Australian Standard on Laundry Practice.126 In its report, the accreditation agency brought the non-compliance to the DHB’s attention and, as a result, the infection control team’s concerns were addressed.

Survey Responses on Consultation About Waste Management Contracts

5.85
All hospital services had contracted out their waste management. Twelve said that their infection control team was always involved in reviewing the contract.127 Three reported that they never involved their team in such reviews.

Survey Responses on Consultation About Cleaning Arrangements

5.86
Cleaning standards for public hospitals have been established in Australia by the Victorian Government128 and in the United Kingdom by the Infection Control Nurses Association.129 No cleaning standards have been established for New Zealand public hospitals.

5.87
The routine work of infection control practitioners can enable them to gain the skills and knowledge they need to provide reliable advice on cleaning and hygiene standards. For example, 18 infection control teams said they had undertaken audits of cleaning standards, which they generally do as part of broader audits of hospital hygiene.130 A number of teams said they reported on matters such as the need for changes in the cleaning schedule or the need for more training of cleaning staff.

"… Infection control had considerable input into the last round of cleaning contract negotiations …"

5.88
One respondent outlined the following areas for improvement that arose from a review of the cleaning contract by an infection control practitioner:

  • the need for extra cleaning duties in specified clinical areas; and
  • improved cleaning specifications for certain areas and equipment – the practitioner helped devise the specifications, recommended what areas needed additional cleaning, how often, and the additional time required.

5.89
Of the 19 hospital services that had contracted out cleaning services, only nine always consulted the infection control team when reviewing the cleaning contract.131 By excluding infection control staff, there is a risk that infection control matters will not be sufficiently considered in the contracting process.

Conclusions

5.90
Through their contacts and hospital-wide experience, infection control practitioners often know a lot about how the hospital works. Involving them in changes to the hospital environment helps to ensure that the practical consequences are fully considered. We noted that where the practitioners were involved in reviews of equipment, buildings, catering, laundry, and cleaning, they provided useful advice that could improve the quality of decisions.

5.91
We were disappointed at the limited consultation with infection control practitioners on such matters. We regard this as a missed opportunity to minimise infection control risks.

Recommendation 27
The infection control team should be consulted when changes to the hospital environment (including contracting of services) are proposed.

94: Infection control and the hospital pharmacy also need to work effectively together – this relationship is mainly considered in Part Seven on Screening and Surveillance to Identify Hospital-acquired Infection (see pages 151-172).

95: F2: Q19 & Q20.

96: F2: Q21, A.

97: F2: Q21a, B – f, k, j.

98: F2: Q21a, B.

99: F2: Q21a, B – n, b, h – out of 21 hospital services; this includes hospital services that excluded these categories of staff as members (see Figure 9 on page 104).

100: F2: Q22.

101: F2: Q24, A.

102: F2: Q23.

103: F2: Q24, B, c.

104: F3.1: Q20 & Q23.

105: F3.1: Q21 & Q26.

106: F3.3: Q6a.

107: AS/NZS 4360:1999.

108: In a colonised person, the organism is present in the person’s body but has not caused an infection in that person.

109: F3.1: Q30.

110: F3.1: Q31a & Q31b.

111: F3.1: Q39a.

112: F3.1: Q39b.

113: F3.1: Q40, A & B.

114: F3.1: Q42.

115: F3.1: Q43a – one assessed the laboratory as “fairly effective”; none assessed the laboratory as “not at all effective”.

116: F3.1: Q43b.

117: The term health care services means services that are hospital care, residential disability care, rest home care, or specified health or disability services.

118: F3.1: Q28.

119: Epidemiology is the study of the distribution and determinants of health and disease in the community.

120: F2: Q14a & Q14b.

121: F3.1: Q29.

122: F3.1: Q8.

123: F3.1: Q9.

124: F3.1: Q10, a – two hospital services did not contract out their catering service.

125: F3.1: Q10, b – six hospital services did not contract out their laundry service.

126: AS 4146:1994 Laundry Practice published by Standards Australia – this standard is cited in the New Zealand Infection Control Standard.

127: F3.1: Q10, c.

128: At www.vic.gov.au.

129: Standards for Environmental Cleanliness in Hospitals (see www.cleanhospitals.com).

130: F3.3: Q26b, A, b.

131: F3.1: Q10, d.

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