Part 6: Setting Infection Control Policies, Educating People to Follow the Policies, and Making Sure They Do

Management of Hospital-acquired Infection.


All people working in hospital services need to be clear about what they need to do (and not do) in order to meet infection control requirements. Clear guidance is achieved by:

  • establishing and documenting infection control policies and procedures;
  • educating people working in hospital services about the policies and procedures and how to apply them; and
  • auditing clinical and other hospital practices to ensure that staff are following the policies and procedures as they undertake their day-today tasks.

In this part we examine:

  • what infection control policies and procedures are in place and what they cover;
  • training and education of hospital staff in infection control;
  • auditing the application of infection control policies and procedures;
  • hygiene audits;
  • monitoring of compliance with antibiotic policies; and
  • involvement of infection control staff in clinical audits.

What Infection Control Policies and Procedures Are in Place and What Do They Cover?

Policies and procedures for infection control – which should be endorsed by the infection control committee – generally fall into one of two categories:

  • those that apply to the hospital as a whole; and
  • those that are relevant to a specific part of the hospital or to a particular activity.

Survey Responses on Manual of Policies and Procedures

The policies and procedures should be readily available to the infection control team – for example, in a manual that is regularly reviewed and updated.

We asked whether hospital services had an infection control manual containing generic (i.e. applying throughout the hospital service) infection control policies and procedures, and how often these were updated.

"… Policies and procedures are clear and available on the hospital intranet site … "

All hospital services reported that they had a manual containing generic infection control policies and procedures that was available to the infection control team.132 Guidance being used in one hospital service, for the control of specific infectious organisms, illustrated particularly well the important components of a comprehensive statement of infection control policy:

  • a clear purpose and scope;
  • clearly assigned roles and responsibilities within the hospital service – including responsibilities for adequate resourcing, communications, record-keeping, and clinical practice;
  • measures to prevent the transmission of infectious organisms – including education, screening, procedures for the management of colonised or infected staff, and isolation of infected patients; and
  • the maintenance of patient records for infection tracing and identification, and the provision of information to the patient.

Almost all infection control teams updated their manual at least every three years.133 One hospital service that we visited highlighted the value of its document control system in providing:

  • a clear record of the status of policies, procedures, and guidelines, showing when they were issued and due for review; and
  • easy reference for staff.

Figure 12
Does an Infection Control Procedure Exist?134

Hand hygiene210
Standard Precautions210
Transmission-based Precautions21 0
Management of patients with known or suspected TB 210
Prevention and follow-up of needle-stick injury/blood/body-fluid exposure21 0
Re-use of single-use items210
Waste management 210
Pre-employment screening 201
Insertion and management of intravascular device192
Screening of patients183
Investigation of outbreaks 183
Disinfectant and antiseptic policy 18 3
Purchasing of equipment183
Prevention and management of infection in hospital staff17 4
Laundry practice 174
Management of immuno-compromised patients156
Management of non-immune and colonised staff 156
Management of urinary catheter systems 156
Care of wounds and management of surgical drains15 6
Staff vaccination policy147
Antimicrobial135 usage147
Pest control 12 9
Environmental standards for patient care areas 129
Aseptic techniques13610 11
Bed management813

Survey Responses on What Policies and Procedures Are in Place

Hospital services had infection control policies and procedures for most of the activities specified in the Standard.137 For example, Figure 12 (on the previous page) shows that all hospital services had procedures covering hand hygiene; Standard Precautions; Transmission-based Precautions138; and re-use of single-use items. In addition, they all had procedures for the management of patients with known or suspected tuberculosis (TB); prevention and follow-up of needle-stick injury/blood/body-fluid exposure; and waste management.

"… Once again the actions taken following the finding of MRSA within the surgical area re-emphasised the importance of hand hygiene, including the use of alcohol-based hand rubs and adherence to Standard Precautions at all times …"

The extent to which each hospital service had procedures covering the 25 items in Figure 12 varied. Figure 13 below shows that one hospital service had procedures for only 13 of the 25 items – of particular concern since this was a DHB with tertiary services, where the risks are particularly high and infection control procedures are especially important. Seventeen DHBs had procedures for 19 or more of the 25 items – and two of the smaller DHBs had procedures for all 25 items.

Figure 13
Extent of Infection Control Procedures, by Hospital Service

Figure 13.

Innovative policies, procedures, practices, and guidance for staff can have a big impact on the detection, reporting, and management of infections – with benefits for patient and staff safety. One hospital service had introduced a blood/body-fluid exposure kit containing:

  • information about first-aid procedures;
  • instruction sheets and a checklist for staff;
  • guidelines for obtaining consent to take a sample;
  • patient information;
  • specimen tubes for blood or body-fluid samples; and
  • laboratory and incident forms.

After introducing the kit, the number of reported instances of exposure increased markedly over the number reported in the previous year, giving a more comprehensive picture of risks to staff. Such initiatives can also support more detailed reporting of the causes of infection – information that can then be used to improve staff education programmes in the areas of highest risk and, more generally, to improve infection control practice.

Moving patients increases the risk of spreading infection. However, some transfers of hospital patients between cubicles in the same ward or to different wards can be inevitable when there is high demand for beds. Bed management policies should set out procedures for dealing with large numbers of patients and limited bed capacity – in the interests of minimising movements of patients and thereby reducing the risk of spreading infection. However, only eight hospital services said they had a bed management policy.139

In addition, some hospital services had no infection control policies governing important areas of clinical practice such as the application of aseptic techniques, the management of patients with urinary catheters, care of wounds, and/or management of surgical drains.140

Survey Responses on Procedures for Re-use of Single-use Items

For reasons that include patient safety, many hospital equipment items are used only once.141 When items intended for a single use are processed for re-use, the processing is often technically complex and, if not strictly controlled, can pose risks for patient safety.

Since 2001, the United States Food and Drug Administration has required single-use items to be processed for re-use to the same quality assurance and safety criteria used by the original manufacturer – a requirement that has virtually stopped the re-use of such items in US hospitals.142 Financial implications arise from adopting this approach.

In New Zealand, the Ministry has been working mainly with relevant Australian bodies on the re-use of single-use items. Developments have included:

  • In December 1994, Medsafe – the New Zealand Medicines and Medical Devices Safety Authority, a business unit within the Ministry – circulated an article from the publication Prescriber Update to every medical practitioner in the country. The article stated that users should always follow the manufacturer’s recommendation on re-use unless there was documented evidence to support a deviation. There should be written policy or guidelines for such deviations and documentation to cover all aspects of safety and performance of a device.
  • In 1995, the Australian National Health and Medical Research Council Expert Panel produced a report on re-use of medical devices labelled as single-use, containing 14 recommendations. The New Zealand Ministry of Health was represented on a working party established in 1997 to advise on the implementation of the recommendations. In 1998, the Ministry reminded hospital and health care services of the December 1994 publication and provided a summary of progress on the working party’s project.

The Ministry has continued to monitor international developments. We understand that Medsafe has plans to update hospital services on these developments in the near future, and to make recommendations on any appropriate action.

In the meantime, the country’s hospital services follow the Australian Standard AS 4187 (now a joint standard143) on cleaning, disinfecting, and sterilising re-usable medical and surgical equipment (including single-use items that the hospital service has decided to re-use). The standard recommends that single-use items be discarded appropriately after use according to local regulations.

The Infection Control Standard (the Standard) requires hospitals to have a policy on single-use items, and notes that processing these items for re-use may present risks to patients.144 Any re-use of items intended for singleuse requires carefully controlled processing. Arrangements for re-use should include:

  • clear designation of items intended for a single use;
  • procedures for approval for such items to be processed for re-use;
  • staff who have the skills and expertise to set appropriate processing standards for re-use and to check individual pieces of equipment for compliance with the standards; and
  • periodic audits to ensure that any processing for re-use is carried out consistent with the manufacturer’s specifications, and in a way that manages any associated infection risks and preserves the integrity of the equipment.

All hospital services had procedures on the re-use of single-use items.145 For example, in one hospital service, designated single-use items could be re-used only with the approval of a committee convened for that purpose. For each item, the committee also assigned a date by which it must review and confirm its approval before the item could continue to be re-used. In this way, the committee performed an important quality control function through its oversight of an area of hospital practice that is recognised as presenting a particular set of risks for patient safety.


Infection control teams and other hospital staff had ready access to documented, up-to-date infection control policies, procedures, and practices – both for day-to-day reference and guidance, and to use as a benchmark for auditing against good practice.

Most hospital services had in place procedures for those activities specified in the Standard. However, when assessed against a wider range of aspects of clinical or other hospital practice for which hospitals might be expected to have procedures, coverage was more variable. Some hospital services had comprehensive procedures, while others had no infection control procedures for some important aspects of clinical or other hospital practice.

All hospital services had procedures to manage the risks associated with the re-use of items intended for single-use. However, the issues relating to such re-use are complex. In our view, national consistency in approach and practice would be prudent, and would enable proper consideration of the financial implications of the more cautious practices being adopted or under consideration overseas.

Recommendation 28
Hospital services should review the scope of their infection control policies, procedures, and practices to ensure that they cover all relevant activities.
Recommendation 29
The Ministry should consider establishing a working party to review information on overseas practices and developments on the re-use of items intended for a single use, with a view to providing timely guidance to DHBs.

Policies on the Use of Antibiotics

Antibiotics are used to treat bacterial infections (known as therapeutic use of antibiotics). They are also used for prophylactic treatment – to help prevent infections occurring in patients undergoing certain procedures, such as cardiac or orthopaedic surgery.

The widespread use of antibiotics worldwide has led to the emergence of highly resistant strains of bacteria. The risks posed by such bacteria are greatest where:

  • antibiotic use is high;
  • sick patients are in close contact; and
  • conditions in the hospital ward or department allow organisms to spread.

In August 2001, the Ministry reviewed antibiotic usage to monitor the progress DHBs were making towards implementing the Standard. The review found most DHBs had policies (either final or in draft) for the prudent prescribing of antibiotics for treating infections. Fewer had policies for the use of antibiotics to prevent infection, or processes to evaluate compliance with their policies. The Ministry recommended that DHBs achieve compliance by June 2002.

Survey Responses on Antibiotic Policies

We asked each hospital service:

  • whether it had policies or guidelines for the use of antibiotics; and
  • who controlled antibiotic policies or guidelines.

Most hospital services had policies or guidelines for the therapeutic and prophylactic use of antibiotics.146

Policies or guidelines were most commonly controlled by a Medicines Review Committee or equivalent, in conjunction with clinicians.147 The committee usually included pharmacists and medical microbiologists.

Doctors and midwives (in treating pregnant women) prescribe a range of antibiotics to control a variety of organisms, and need easy access to information about the resistance of particular organisms to specific antibiotics:

  • One hospital laboratory had designed a reference sheet listing organisms and the extent to which each was resistant to particular antibiotics. As well as providing a helpful aid to doctors, the reference sheet established a useful benchmark for auditing compliance.
  • An infection control team had designed laminated antibiotics tags to be attached to doctors’ name tags. This was an innovative way to remind medical staff about the correct antibiotics to be prescribed.


Most hospital services had policies or guidelines for the appropriate use of antibiotics. Medicines Review Committees (which most commonly control the policies governing the prescribing of antibiotics) had a broad membership, helping to ensure that decisions about antibiotics recommended for use took account of current patterns of bacterial resistance within the hospital.

Keeping Infection Control Policies and Procedures Up To Date

Survey responses and discussions with infection control practitioners suggested that infection control teams are spending a substantial amount of time drawing up and reviewing infection control policies (14% of infection control practitioner time on average)148. As clinical practices change, policies need to be reviewed. And, as hospitals prepare for certification, this aspect of infection control practitioners’ work is likely to grow.

Infection control policies and procedures need to reflect the particular hospital environment where they will be applied. However, some apply equally to any hospital environment. Smaller infection control services are likely to find it difficult to draw up and maintain a full range of infection control policies. Although infection control practitioners sometimes get together at events such as conferences to share good practice, we found little evidence that infection control services were seeking to share expertise and experience, collaborate actively, and/or exchange information on common issues.


Drawing up infection control policies and keeping them up to date is time-consuming and the work involved is likely to increase as hospital services prepare for certification. Many aspects of policies are applicable to all hospital services, and infection control services could benefit from greater sharing of policies, procedures, and best practice throughout the public health sector.

Recommendation 30
DHBs should explore using the Health Intranet maintained by the Ministry to facilitate communication and collaboration, and to share educational material and information on policies, procedures, best practice, and local initiatives.

Training and Education for Hospital Staff in Infection Control

Maintaining personal hygiene and following good work practices are essential in preventing hospital-acquired infection. Hospital staff should receive education and training during induction. Thereafter, they should undergo refresher training at regular intervals to remind them of good practice.

The training should be tailored to reflect the particular services provided in the hospital and the wide range of educational abilities and work responsibilities of particular staff. As a minimum, training should include:

  • instruction on hand hygiene, aseptic practices, and Standard Precautions;
  • strategies and good practice for isolating infectious or at-risk patients; and
  • how to prevent exposure to blood and body-fluids.

The effectiveness of infection control training should be assessed periodically, to review the focus and effectiveness of training programmes.

Survey Responses on Infection Control Training of Hospital Staff

We asked, in regard to training provided by the infection control team to other health care workers, whether the effectiveness of the training had been assessed, and what were the outcomes of the assessment.

Nurses and midwives have high levels of contact with patients, making it vital that they are aware of the need to follow scrupulous hygiene practices, and the health risks associated with lack of hygiene. All hospital services reported that their infection control teams provided infection control training to newly appointed nurses and/or midwives.149

In 18 hospital services, new resident medical staff (generally house surgeons or registrars) also received training in infection control.150 However, only one-third provided such training for newly employed senior doctors151, creating the risk that their practices may be inconsistent with the organisation’s policies.

Eighteen hospital services provided annual updates on infection control for nurses and/or midwives.152 However, only two and four respectively provided such training for senior doctors and resident medical staff.153

"… The [infection control] team has ongoing issues around getting staff to training in the numbers they would like …"

Cleaners and other staff providing support services in the hospital come into contact with facilities and equipment. They need to know and follow basic infection control practices, otherwise they could create risks for their own safety and the safety of others. However, our survey indicated that fewer than half of the hospital workers in the categories we specified (cleaners, hospital orderlies, and food-handling staff) received any training in infection control.154

Providing simple written explanations and instructions on key infection control policies in the hospital can be a useful way to convey important messages to staff. A handbook published by one infection control team outlined sensible precautions and good practice including:

  • the benefits of vaccination for staff safety;
  • the importance of thorough hand hygiene;
  • advice on how to avoid acquiring infections from patients, and the precautions to be followed when caring for patients in isolation;
  • practices to prevent a needle-stick injury and what to do if one happens;
  • work restrictions for staff with infectious conditions or skin problems; and
  • information about the most common and hazardous organisms.

The handbook also told staff whom to contact for advice.

A few infection control teams published newsletters or contributed articles to a hospital newsletter. These publications can help to keep staff informed of infection control matters within the hospital service and maintain awareness of good practice.

One infection control team published a quarterly newsletter Lurgy Literature. The newsletter contained articles on infection control matters in different parts of the hospital. For example, the edition sent to us:

  • listed members of the infection control committee;
  • alerted staff to the hospital’s updated Meningococcal Disease Contact Policy;
  • informed staff about MRSA and measures to prevent its occurrence and contain its spread;
  • invited staff to comment on a draft occupational health policy;
  • contained guidance for the prevention of surgical site infection; and
  • provided advice on when latex or vinyl gloves should be used.

Targeted education programmes can be effective in reducing the incidence of hospital-acquired infection. A refresher programme in an overseas hospital, showing staff how to insert catheter tubes into veins, resulted in a 64% reduction in infection of catheter sites and a 67% reduction in the number of associated bloodstream infections.155

Thirteen respondents had assessed the effectiveness of staff training in infection control.156 All but one of the assessments covered staff awareness, understanding, and compliance with infection control procedures.157 The assessments were particularly valuable because they158:

  • identified instances of poor infection control practice;
  • provided people working in the hospital with useful feedback on whether they were meeting standards of good practice; and
  • formed the basis for any necessary follow-up action.


Effective infection control practice cannot be achieved without the commitment of well-informed and trained staff. Training in good practice and familiarity with organisational policies and procedures helps to promote a culture of good infection control practice throughout the hospital.

All hospital services reported that their infection control teams provided infection control training to newly appointed nurses and/or midwives. Some staff groups (in particular, senior doctors and support services staff) were much less likely to receive infection control training, either on appointment or as refresher training – creating the potential for awareness and commitment to decline, and for standards of practice to slip.

Assessments of the effectiveness of training provided valuable information on the practice of infection control.

Recommendation 31
Hospital services should:
• ensure that all hospital staff – including doctors and support services staff – receive training in infection control when they join the hospital; and
• provide refresher training to all relevant staff to maintain awareness and encourage compliance with standards.

Auditing the Application of Infection Control Policies and Procedures

In Part Four, we noted the small amount of time that infection control staff in some hospital services spent on auditing compliance with infection control procedures (see paragraph 4.43 on page 89).

[Value of Audit] "... on occasions to congratulate the ward/unit on excellent compliance with infection control policies/processes …"

Audits are an important source of assurance about compliance with safe practice and should be viewed as a key component of a hospital’s management of risk.In any organisation, auditing of policies and procedures serves two vital purposes:

  • to monitor compliance; and
  • to identify any difficulties in putting policies and procedures into practice, and any need to improve them.

Survey Responses on the Audit of Policies and Procedures for Infection Control

We asked whether compliance with the infection control procedures for the items listed in Figure 12 (on page 131) had been audited in the previous 12 months.

Hospital services had undertaken only limited auditing of compliance159, even for procedures required by the Standard:

  • Hand hygiene is widely recognised as essential for preventing infection, but only 13 hospital services had audited compliance with hand hygiene procedures.160
  • Only 10 had audited compliance with Standard Precautions.161
  • Only nine had audited re-use of single-use items.162
  • Only four had audited prevention and management of infection in hospital staff.163

We specifically examined the responses from the six hospital services with tertiary hospitals. We expected these hospital services to have a strong infection control audit programme in place, in view of the fact that they treat large numbers of the most sick and vulnerable patients who often undergo hospital treatment that is relatively complex and risky. However, in the previous 12 months, few procedures had been audited:

  • one of the six hospital services had audited compliance with seven procedures;
  • two had audited compliance with six procedures; and
  • the other three had audited compliance with three or fewer procedures.

Survey Responses on Audits of Hospital Hygiene

Audits of hospital hygiene can make a substantial contribution to infection control by ensuring that:

  • staff follow good practice in their day-to-day work;
  • equipment is clean, and disinfected or sterilised where necessary; and
  • hospital facilities are maintained and cleaned to an appropriate standard.

We asked infection control teams:

  • whether they had carried out an audit of hospital hygiene;
  • what such audits covered;
  • whether they produced reports of findings; and
  • who received those reports and what changes resulted.

All infection control teams had carried out an audit of hospital hygiene.164 The majority had covered most key areas:165

  • Most had audited at least six of eight key areas.
  • However, three teams had carried out audits in fewer than four of the eight key areas.
  • All audits had been carried out within the previous two years.

Good standards of hygiene often involve having the personal discipline to undertake a simple, repetitive task – such as washing your hands – frequently and thoroughly. For people to maintain personal discipline, they need a good standard of facilities – such as clean washbasins in working order – that enable them to undertake the task efficiently as part of their normal routine. One audit by an infection control team found that more than half of hand-washing facilities had major faults:

  • one in four basins was blocked;
  • taps were faulty;
  • one in 10 basins had no soap;
  • rubbish bins to collect paper towels were not available, were overflowing, or had faulty lids; and
  • there were no paper towels for drying hands.

The team also found minor faults in more than 80% of the hospital’s hand-washing facilities.

"[Hand-washing] ... generally good compliance from nurses – less from medical staff …"

The findings led to an investigation into hand hygiene products that might be as effective as normal washing with soap and water, as well as being acceptable to staff. Other improvements arising from hygiene audits that were reported to us included166:

  • revised ward-cleaning schedules;
  • a decision to involve infection control staff in cleaning contract negotiations;
  • the use of a new, more effective brand of liquid soap;
  • further education in waste management;
  • re-siting of disinfection facilities away from clinical areas; and
  • changes to the way in which hospital linen was handled.

A hygiene audit in one of the hospitals we visited illustrated the benefits of reinforcing good practice through audits. The audit had reviewed daily practice against the hospital’s directive that all staff must wash their hands after physical contact with patients. During the ward rounds conducted by five consultants, it was noted that not all washed their hands after physical contact. This was particularly worrying as four patients examined during the rounds were potentially infectious.

The results of the audit were brought to the attention of the consultants, reminding each of the importance of careful hand hygiene to avoid the risk of transmitting infection from one patient to another.

We commend this audit as a good example of how an infection control team was supported in reviewing the practices of senior staff. This type of audit can only be done effectively in an environment committed to, and supportive of, a thorough hospital-wide approach to the prevention of hospital-acquired infection.

Promotional activities can foster good infection control practice, reinforcing lessons from periodic audits. For example, one infection control team had organised a “Hand Washing Week” when staff were encouraged to participate in novel activities illustrating messages about hand hygiene. The campaign was well received and seen as successful in improving staff awareness.

All but two infection control teams produced reports of the findings from their hygiene audits.167 The reports went to the ward that had been audited168 but not all teams circulated them more widely – for example, only 12 gave the reports to members of the infection control committee.169


The amount of auditing being undertaken for compliance with infection control procedures is too low. With so little time assigned to audits, it is difficult to be sure that policies and procedures are being followed – representing a substantial gap in quality assurance.

Hospitals were commonly carrying out audits of hospital hygiene, but some covered only a few areas of the hospital, limiting the assurance available to hospital managers about the safety of the hospital environment.

Audits of hospital hygiene can identify the need for substantial improvements in infection control in a range of hospital practices, procedures, and facilities. Education and promotional activities can reinforce, and make staff aware of, the important messages emerging from such audits.

The findings from such audits can have wider application than for the ward or unit that was audited, but the reports of audits were not always distributed widely. As a result, hospital managers may not be aware of all the lessons that the audits identified.

Recommendation 32
Hospital services should treat auditing compliance with infection control policies and procedures as a core quality assurance activity, and ensure that their infection control teams are adequately resourced to spend the necessary time on this work.

Monitoring of Compliance with Antibiotic Policies

Gaps in the co-ordination of infection control activities and pharmaceutical practices create the risk that hospitals will not make the necessary associations between antibiotic resistance and prescribing patterns. We asked whether the infection control team worked with the pharmacy to ensure compliance with antibiotic policies or guidelines.

Survey Responses on Compliance with Antibiotic Policies

Only 10 hospital services had members of the infection control team working with their pharmacy on compliance with antibiotic policies and guidelines.170 Figure 14 describes how one hospital we visited supported compliance through ongoing analysis and reporting of antibiotic usage and patterns of bacteria resistance.

Figure 14
Reporting Antibiotic Usage and Patterns of Bacteria Resistance

Reporting Antibiotic Usage and Patterns of Bacteria Resistance
One hospital pharmacy regularly surveyed the practices of hospital departments and discussed the issues with staff, including members of the infection control team. Using this information, the pharmacy reported antibiotic use every six months to the hospital’s Medicines Review Committee. Patterns of bacteria resistance were reported annually. These sets of information were then used to assess and update the hospital’s list of preferred antibiotics.

We asked whether the infection control team had any concerns about non-compliance with antibiotic policies or guidelines, and how any such concerns were being addressed. Seventeen infection control teams had concerns about non-compliance with antibiotic policy or guidelines.171 Their concerns were being addressed in a range of ways, such as by bringing them to the attention of the relevant committee – the infection control committee or the drugs and therapeutics committee.172


Ensuring compliance with antibiotic policies requires close collaboration between the infection control team and pharmacy staff. We were therefore concerned that in more than half the hospital services, the infection control team and the hospital pharmacy were not working together to ensure compliance with these policies.

Recommendation 33
Hospital services should consider the need to review how well the infection control team and the hospital pharmacy are working together to ensure compliance with antibiotic policies.

Involvement of Infection Control Staff in Clinical Audits

Elsewhere in the report (see, for example, paragraphs 5.1-5.4 on page 101) we have emphasised:

  • the hospital-wide role and presence of the infection control team;
  • the broad knowledge and expertise that the team builds up as a result of its role and presence; and
  • the value of using this knowledge and expertise in activities throughout the hospital where infection control is a relevant consideration.

Clinical audit173 is a central feature of clinical quality assurance. Much of an infection control team’s work is closely related to clinical audit. Clinical audits undertaken by other hospital staff may also help to identify infection control risks associated with hospital practices and the hospital environment.

The results of clinical audits should be made available to appropriate members of the infection control team or committee, so that any necessary improvements can be identified and action taken. In some cases it may be useful to involve infection control staff in the design of a clinical audit, ensuring that the audit addresses relevant infection control issues.

Survey Responses on Involvement in Clinical Audits

We asked whether the infection control team contributed to the drawing up of standards in clinical services, and whether the team assisted in auditing compliance with those standards. We also asked about the focus of clinical audits in 2000-01, and how the results of the audits were used.

Nineteen infection control teams said that they contributed to the drawing up of standards in some other clinical services. Fourteen teams said that they assisted in auditing compliance with the standards.174

We identified seven clinical facilities and processes175 for which we expected that the infection control team might be involved in clinical audits. Responses varied widely:

  • all infection control teams were involved in audits of sharps’ disposal176, 177;
  • 16 were involved in audits of the use of intravenous devices178;
  • only nine were involved in audits of isolation units179; and
  • only five were involved in audits of wound care180.

One clinical audit illustrated the benefits of infection control staff being involved in an audit of the use of intravenous catheters. These medical devices can cause complications, including infection. In 2001, following earlier similar studies in 1994, 1997, and 1998, the infection control nurses collected data on 577 patients who had catheters inserted. The audit showed an infection rate of 6.5% – an increase from previous years when the rate had been as low as 1.1%. The audit report recommended that hospital staff:

  • monitor the length of time catheters were left in place;
  • improve documentation in clinical notes about the insertion and management of catheters; and
  • receive further education on aspects of care for intravenous catheters and administration of drugs.

All but one hospital service said that the infection control results of clinical audits were reported to a range of appropriate staff.181 Eighteen infection control teams had identified specific infection control training needs from the audits182, including:

  • ongoing education in contact precautions and compliance with standard hygiene practices;
  • dealing with multi-resistant organisms; and
  • handling of sharps’ containers.


Most infection control teams were helping to draw up standards for clinical services, but fewer assisted in auditing compliance with those standards. Teams were involved in audits of some clinical facilities and processes but not others – for example, isolation units and wound care – potentially weakening their focus on infection control risks.

Where infection control teams are involved in such audits, they can use the findings to help identify opportunities for improvements in infection control – such as the need for specific infection control training.

Recommendation 34
Infection control teams should be involved in the design and conduct of clinical audits (as members of the audit team or indirectly through consultation or discussion) to ensure that such audits have regard to infection control risks associated with clinical facilities and processes, and to identify opportunities for improvement in infection control practices arising from audit findings.

132: F3.3: Q9a.

133: F3.3: Q9c.

134: F3.3: Q11, A – we selected this list of items for which a hospital service might be expected to have policies and procedures as a part of the planning and pilot phase of our survey.

135: This is the term we used in our survey. We have used the more familiar term “antibiotic” throughout our report.

136: Aseptic techniques are procedures used to minimise the transfer of infection.

137: NZS 8142:2000, paragraph 4.5, page 15 – Policies and procedures shall include but are not limited to: hand hygiene; Standard Precautions; transmission-based precautions; prevention and management of infection in service providers; antimicrobial usage; outbreak management; cleaning, disinfection, sterilisation; and single-use items. (Variously covered by F3.3: Q11, A).

138: Standard Precautions are taken in relation to all patients and include hand washing, glove use, and use of barrier protection. Transmission-based Precautions are used alongside Standard Precautions to reduce the risk of airborne droplet and contact transmission.

139: F3.3: Q11, A – d.

140: F3.3: Q11, A – p, r, s (respectively) – see Figure 12 on page 131.

141: The costs of safely processing for re-use to the manufacturer’s specifications may also be a consideration.

142: Requiem for Re-use of Single-use Devices in US Hospitals; published in Infection Control and Hospital Epidemiology (an official journal of the Society for Healthcare Epidemiology of America); Vol. 22(99), September 2001.

143: AS/NZS 4187:2003 – Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities.

144: NZS 8142:2000, page 15.

145: F3.3: Q11, A – t.

146: F3.1: Q11.

147: F3.1: Q12.

148: F3.2: Q2, A – f.

149: F3.1: Q2, A – d.

150: F3.1: Q2, A – b.

151: F3.1: Q2, A – a.

152: F3.1: Q2, B – d.

153: F3.1: Q2, B – a, b.

154: F3.1: Q2, A – h, i, j.

155: Eggimann P, Pittet D; Overview of Catheter-related Infections with Specific Emphasis on Prevention-based Educational Programs; Clinical Microbiology and Infection; Vol. 8, No. 5, May 2002.

156: F3.1: Q3a.

157: F3.1: Q3b.

158: F3.1: Q6 & Q7.

159: F3.3: Q11, C.

160: F3.3: Q11, C – a.

161: F3.3: Q11, C – b.

162: F3.3: Q11, C – t.

163: F3.3: Q11, C – l.

164: F3.3: Q26a.

165: F3.3: Q26b – we identified eight key areas on which we expected audits of hospital hygiene to focus:
• collection and disposal of waste;
• building cleanliness;
• procedures for cleaning, disinfection and sterilisation;
• food hygiene;
• personal protective equipment;
• hand hygiene;
• hand basins; and
• cleanliness of ward facilities (toilets, bathrooms, kitchens).

166: F3.3: Q30.

167: F3.3: Q28.

168: F3.3: Q29, A.

169: F3.3: Q29, D.

170: F3.1: Q13.

171: F3.1: Q14a.

172: F3.1: Q14b.

173: Clinical audit seeks to: improve the quality and outcome of patient care through structured peer review whereby clinicians examine their practices and results against agreed standards and modify their practice where indicated – definition taken from Clinical Audit in the NHS, UK National Health Service Executive, 1996.

174: F3.3: Q31.

175: The facilities and processes were: isolation units; use of intravenous devices; wound care; sharps’ disposal; appropriateness of prophylactic prescribing of antibiotics; the pre-employment screening programme; and vaccines for influenza and pneumococcal prophylaxis.

176: “Sharps” refers to objects or devices with sharp edges or points capable of cutting or penetrating the skin and causing a needle-stick injury.

177: F3.3: Q32, d.

178: F3.3: Q32, b.

179: F3.3: Q32, a.

180: F3.3: Q32, c.

181: F3.3: Q34a & Q34b.

182: F3.3: Q35.

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