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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 5.3 Clinical support processes

Our practice has working processes that support safety and the quality of clinical care.

Criterion 5.3.3

Healthcare associated infections

Our practice has systems that minimise the risk of healthcare associated infections.

Indicators

► A. Our practice team can identify the person with primary responsibility for coordinating infection control processes within our practice and this person has such responsibility defined in their position description.

► B. Our practice has a written, practice specific policy that outlines our infection control processes.

► C. The practice team member with delegated responsibility for the sterilisation process can describe in detail how sterile procedures are undertaken, including, where relevant:

  • provision of an adequate range of sterile reprocessed or disposable equipment
  • procedures for having instruments sterilised off site, including documentary evidence of a validated process
  • procedures for on site sterilisation of equipment, including monitoring the integrity of the whole sterilisation process, validation of the sterilisation process and steriliser maintenance
  • safe storage and stock rotation of sterile products.

► D. All members of our practice team can demonstrate how risks of potential cross infection within our practice are managed (as appropriate) including procedures for:

  • hand hygiene
  • the use of personal protective equipment (PPE)
  • triage of patients with potential communicable disease
  • safe storage and disposal of clinical waste including sharps
  • managing blood and body fluid spills.

► E. Our practice is visibly clean.

► F. The practice team member with delegated responsibility for environmental cleaning can describe the process for the routine cleaning of all areas of the practice and can provide documentation on the practice’s cleaning policy.

► G. The practice team member with delegated responsibility for staff education on infection control can describe how the induction program for new staff covers our infection control policy as relevant to their role, and the requirements for providing ongoing staff education and assessing staff competency.

► H. Subject to the informed consent of individual practice team members:

  • the natural immunity to vaccine preventable diseases or immunisation status of practice team members is known
  • staff members are offered NHMRC recommended immunisations, as appropriate to their duties.

► I. Our practice team can explain how patients are educated in respiratory etiquette, hand hygiene and precautionary techniques to prevent the transmission of communicable diseases.

Explanation

Key points

  • The practice needs a team member with primary responsibility for coordinating infection control processes
  • The practice needs a written infection control policy
  • All practice staff need to be offered immunisation appropriate to their role in the practice, in accordance with occupational health and safety obligations
  • The practice team needs support for ongoing education to sustain effective infection control
  • This criterion cross references to Criterion 3.1.3 Clinical governance.

Allocation of responsibility

The practice should appoint one member of staff with primary responsibility for infection control processes. Specific areas of responsibility can be delegated to other nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions (eg. infection control processes, sterilisation process, environmental cleaning, staff immunisation, staff education).

Key elements of an infection control policy

The practice’s written infection control policy should include:

  • immunisation for staff working within the practice in accordance with recommendations in the current Australian Immunisation Handbook
  • the appropriate use and application of standard and transmission based precautions
  • sharps injury management
  • blood and body substance spills management
  • hand hygiene
  • environmental cleaning of both clinical and nonclinical areas of the practice
  • aseptic and sterile procedures for disposable instruments and/or instruments sterilised on site or off site. If sterilisation is performed on site, the policy needs to include the procedure for instrument reprocessing, sterilisation and the validation process. If sterilisation is performed off site, the policy needs to include evidence of the validation process and appropriate and safe transport arrangements
  • waste management, including the safe storage and disposal of clinical waste and sharps
  • access for patients and staff to personal protective equipment (PPE) and evidence of education on the appropriate application, removal and disposal of PPE
  • pathology testing done within the practice.

Additional evidence

In addition to an infection control policy, practices need to provide evidence of:

  • the ongoing education and training in infection control provided to each staff member and the mechanism for assessing staff competency in infection control procedures
  • cold chain monitoring
  • monitoring of the sterilisation process and sterilisation equipment maintenance if applicable (practices performing on site sterilisation)
  • annual validation records if applicable (practices performing on or off site sterilisation)
  • staff immunisation records.

Sterilisation processes

In terms of the reprocessing of reusable equipment, the RACGP Infection control standards for office based practices (4th edition) recommends sterilisation as the preferred process for the reprocessing of all reusable instruments and equipment (noncritical, semi critical and critical) that can withstand this process, regardless of their intended use.

Where the practice uses off site sterilisation facilities, the practice needs to be able to document and describe the procedures for safe transport of instruments and equipment to and from the practice and demonstrate that the off site facility correctly performs the sterilisation and validates its processes.

Waste management

Practices are responsible for ensuring compliance with state/territory or local government regulations in relation to waste management. In some jurisdictions, this legislation will override the guidance below.

In relation to waste management within the practice, the RACGP Infection control standards for office based practices (4th edition) define three categories of waste produced by healthcare facilities and outlines the appropriate disposal mechanism for each.

1. Clinical waste: includes discarded sharps, laboratory and associated waste directly involved in specimen processing, human tissue (excluding hair, teeth, urine and faeces unless the patient has a transmissible illness), and materials or solutions containing free flowing or expressible blood.

2. Related waste: includes cytotoxic waste, pharmaceutical waste, chemical waste and radioactive waste.

Disposal of clinical and related waste:

  • for most clinical waste: into a safely located and clearly labelled leak proof container displaying a biohazard symbol
  • for sharps: into a safely located and clearly labelled yellow, leak proof and puncture resistant container displaying a biohazard symbol in all areas where sharps are generated (eg. mounted on a wall or on a bench)
  • a licensed contractor should be engaged to dispose of clinical waste.

3. General waste: includes all waste materials that do not fall into the clinical or related waste categories. General waste contaminated with blood or body substances (though not to such an extent that it would be considered clinical waste (ie. not contaminated with expressible blood), may be disposed of through the general waste process of the practice, but must not be accessible to children. Gauze that has blood on it (but which cannot be expressed), used disposable vaginal spatula, cervical spatula and brushes and tongue depressors are likely to be the most common items in this category.

Disposal of general waste:

  • a bin lined with a leak proof plastic bag which can then be disposed of through the general waste stream
  • the usual waste paper bin under the desk can be used for waste not contaminated by blood or body fluids.

Contaminated general waste and clinical waste must not be accessible to children.

Managing cross infection within the practice

Potential infection risks to the practice team and patients need to be reduced. In this context, it is important for all staff to be familiar with infection control procedures within the practice, including the use of standard and special precautions, spills management and environmental cleaning.

Standard precautions apply to work practices that assume that all blood and body substances, including respiratory droplet contamination, are potentially infectious.

The RACGP Infection control standards for office based practices (4th edition) recommend the use of hand hygiene; PPE, including heavy duty protective gloves, gowns, plastic aprons, masks and eye protection; or other protective barriers when cleaning, performing procedures, dealing with spills or handling waste.

Transmission based precautions are used for patients known or suspected to be infected with highly transmissible infectious agents (eg. influenza). In general practice this may be achieved by minimising exposure to other patients and staff through:

  • the use of PPE (eg. masks)
  • distancing techniques (one metre between patients in the waiting room, isolating the patient in a separate room)
  • effective triage and appointment scheduling, and
  • hand hygiene.

Environmental Cleaning

The practice should have a cleaning policy that sets out a schedule and responsibilities for cleaning all areas of the practice (see chapters 2–5 of the RACGP Infection control standards for office based practices (4th edition).

Where the practice engages commercial cleaners for environmental cleaning, the practice should have a written contract that outlines a cleaning schedule, suitable cleaning products and areas to be cleaned. A cleaning log can be useful.

Staff education

Staff education is crucial to effective infection control within the practice. Education needs to be relevant to the role of particular staff members and needs to start with the staff induction program.

Staff education and the evaluation of staff competency needs to be recorded in line with chapter 1 RACGP Infection control standards for office based practices (4th edition).

Staff immunisation

Practices have an occupational health and safety responsibility to protect their staff from exposure to harmful substances.

Practice staff need to be offered immunisation appropriate to their duties, to ensure they are protected from vaccine preventable infectious diseases. The exact requirements will vary, and need to be assessed according to the risk presented by the type of practice and the duties performed by the staff member.

Practices are advised to check the section of the Australian Immunisation Handbook on recommended vaccinations for healthcare workers available at www.immunise.health.gov.au/internet/ immunise/publishing.nsf/content/handbook-specialrisk238.  The following immunisations can be considered for office based health professionals:

  • hepatitis B
  • influenza
  • pertussis
  • MMR (if non-immune)
  • varicella (if seronegative).

The refusal to be vaccinated or receipt of vaccines and any natural immunity to disease should be recorded in the personnel folder of each staff member. It cannot be assumed that staff will seroconvert post immunisation (eg. hepatitis B). It is therefore recommended that post immunisation status is serologically confirmed wherever possible and that further vaccinations are provided as required. Post-immunisation immunity, if known, should be documented.

Personal protective equipment

All practice staff should have easy access to personal protective equipment and be educated on its proper use (eg. face masks, gloves, gowns, eye protective wear). Staff need to have a clear understanding as to the purpose of this equipment and how to apply, remove and dispose of it appropriately.

Staying up-to-date

It is important that practices remain alert to changes in legislation and guidelines for infection control and be in a position to implement them promptly. General practices should also have systems for monitoring and obtaining information about national and local infection outbreaks and public health alerts, such as pandemic influenza, measles and pertussis outbreaks.

Resources

Useful resources include

Additional resources include

Standard 5.3 Clinical support processes

Our practice has working processes that support safety and the quality of clinical care.

Criterion 5.3.3

Healthcare associated infections

Our practice has systems that minimise the risk of healthcare associated infections.

In a nutshell

Infection control is crucially important to minimising healthcare-associated infections within your health service. This requires the appointment of a team member with primary responsibility for coordinating infection-control processes, supported by a written infection-control policy and ongoing education. There are nine indicators for this criterion, all of which must be met for accreditation against the Standards. Review these important requirements for Criterion 5.3.3 of the Standards for general practices.

See the Other information for Standard 5.3 section of this guide for resources on infection control and waste management for remote health services in the Northern Territory.

Healthcare-associated infections can be minimised when:

  • 
procedures and systems are put in place to ensure compliance with regulatory requirements and standards
  • 
staff are educated, equipped (for example, through immunisation) and have easy access to appropriate personal protective equipment to sustain effective infection control
  • 
compliance is evidenced through documentation of procedures and systems and regular monitoring and updating of processes and policies.

Key team members

  • Staff member responsible for infection control
  • Clinic manager
  • Health service manager
  • All staff

Key organisational functions

  • Clinical risk-management practices
  • Clinical staff personal safety (immunisation)
  • Infection-control policies and processes – for example, hand hygiene
  • Environmental cleaning policy and processes
  • Sterilisation policy and processes
  • Human resources management (staff personal files and records)
  • Occupational health and safety (infection control)
  • Staff ongoing education and training
  • Staff orientation process and package

Indicators and what they mean

Table 5.8 explains each of the indicators for this criterion. Refer to Criterion 5.3.2 Vaccine potency of the Standards for general practices for more information and explanations of some of the concepts referred to in this criterion. See also the list of resources and guidelines for Criterion 5.3.3 Healthcare associated infections of the Standards, including for infection control, pandemic resources, hand hygiene and immunisation.

Because waste management is a more complicated process for remote services, more specific guidelines are available in Appendix A.

Table 5.8 Criterion 5.3.3 Healthcare associated infections
IndicatorWhat this means and handy hints
▶ A. Our practice team can identify the person with primary responsibility for coordinating infection-control processes within our practice and this person has such responsibility defined in their position description. Your health service needs to appoint a team member with primary responsibility for coordinating infection control. Specific areas of responsibility can be delegated to other nominated members of the clinic team. It is advised that all those delegated with this responsibility have it documented in their relevant position descriptions. These responsibilities could include:
  • infection-control processes
  • sterilisation processes
  • environmental cleaning
  • staff immunisation
  • staff education
  • waste management.
▶ B. Our practice has a written, practice-specific policy that outlines our infection-control processes. Your health service needs to have a written infection-control policy that is specific to how things are done in your service. This policy could include:
  • immunisation for staff working within the health service, in accordance with recommendations in the current Australian immunisation handbook
  • appropriate use and application of standard and transmission-based precautions
  • sharps injury management
  • blood and body substance spills management
  • hand hygiene
  • environmental cleaning of both clinical and non-clinical areas of the health service
  • aseptic and sterile procedures for disposable instruments and/or instruments sterilised on site or off site
  • procedures for instrument reprocessing, sterilisation and the validation process, if sterilisation is performed on site
  • validation process and appropriate and safe transport arrangements if the sterilisation is performed off site
  • waste management, including the safe storage and disposal of clinical waste and sharps
  • access for patients and staff to personal protective equipment (PPE) and evidence of education on the appropriate application, removal and disposal of PPE
  • pathology testing conducted within the health service.
The infection-control policy could set out procedures in relation to each of these aspects and the staff member or members responsible.

In addition to infection control, it is highly recommended that your health service have written policies and/or processes that deal with:
  • ongoing education and training in infection control to each staff member, including a description of how your health service assesses staff competency in infection-control procedures
  • cold chain monitoring (see Criterion 5.3.2)
  • monitoring of the sterilisation process and maintenance of sterilisation equipment if applicable (for health services that perform on-site sterilisation)
  • annual validation records if practicable (for health services that perform on- or off-site sterilisation)
  • staff immunisation records.
 ▶ C. The practice team member with delegated responsibility for the sterilisation process can describe in detail how sterile procedures are undertaken, including, where relevant:
  • provision of an adequate range of sterile reprocessed or disposable equipment
  • procedures for having instruments sterilised off site, including documentary evidence of a validated process
  • procedures for on-site sterilisation of equipment, including monitoring the integrity of the whole sterilisation process, validation of the sterilisation process and steriliser maintenance
  • safe storage and stock rotation of sterile products.
Sterilisation processes and equipment need to be coordinated by a team member (for example an infection-control officer) who has been delegated with responsibility for sterilisation and received the necessary training for the role. It is highly recommended that the staff member allocated these responsibilities has them recorded in their job description.

When required, the staff member can describe in detail how sterile procedures are undertaken, including, where relevant, those outlined in this indicator.

The use of policy, procedures and other tools such as checklists is a good way of ensuring that adequate steps have been taken for the complete sterilisation process.
▶ D. All members of our practice team can demonstrate how risks of potential cross-infection within our practice are managed (as appropriate) including procedures for:
  • hand hygiene
  • the use of personal protective equipment
  • triage of patients with potential communicable disease
  • safe storage and disposal of clinical waste including sharps
  • managing blood and body fluid spills.
An important component of infection control is the education and training of staff to ensure that the potential for cross-infection is minimised. This means that all staff need to be familiar with different policies, protocols and procedures that your health service has in place around infection control. These include the infection-control policy and triage protocols.

See Criterion 5.3.3 Healthcare associated infections of the Standards for general practices for more information on waste control.

It is the role of the infection-control officer to coordinate the different policies that relate to infection control. This includes the use and knowledge of standard and special precautions, spills management and environmental cleaning.
▶ E. Our practice is visibly clean. Your health service looks clean, everywhere, all the time.
▶ F. The practice team member with delegated responsibility for environmental cleaning can describe the process for the routine cleaning of all areas of the practice and can provide documentation on the practice’s cleaning policy. Your health service is advised to have a cleaning policy that sets out a schedule and responsibilities for cleaning all areas of the service. Also refer to chapters 2–5 of the RACGP Infection control standards for office-based practices (4th edition).

If your health service pays for commercial cleaners, a written contract is advised, to outline a cleaning schedule, suitable cleaning products and the area to be cleaned. A cleaning log would be most useful.

Environmental cleaning needs to be coordinated by a team member who has been delegated with this responsibility. It is highly recommended that this team member’s responsibilities are recorded in their job description. When required, this team member can describe in detail how environmental cleaning has been undertaken, and provide documentation as evidence (such as your policy or the cleaning log).
 ▶ G. The practice team member with delegated responsibility for staff education on infection control can describe how the induction program for new staff covers our infection-control policy as relevant to their role, and the requirements for providing ongoing staff education and assessing staff competency. It is recommended that your health service has a staff education and training policy specific to infection control.

It is the obligation of the team member delegated with responsibility for staff education on infection control to ensure that staff are adequately trained and educated on infection-control procedures. It is also highly recommended that this team member’s responsibilities are recorded in their job description.

When required, this team member can describe how:
  • your health service’s orientation and induction process covers the infection-control policy, so that all new staff members are aware of their roles and responsibilities around infection control, and who they need to go to for questions about this matter
  • your health service’s infection-control policy provides for ongoing education and training in infection control as relevant to each staff member
  • your health service records staff members’ ongoing training and education around infection control
  • your health service assesses staff competency in infection-control procedures.
▶ H. Subject to the informed consent of individual practice team members:
  • the natural immunity to vaccine-preventable diseases or immunisation status of practice team members is known
  • staff members are offered NHMRC-recommended immunisations, as appropriate to their duties.
Your health service has an OH&S responsibility to protect staff from exposure to harmful substances. In a healthcare setting, this includes the provision of immunisation to all staff members, as appropriate to their duties. Exact requirements may vary, and need to be assessed according to the risk presented by the type of health service and the duties performed by the staff members.

It is highly recommended that you consult the Australian immunisation handbookon recommended vaccinations for healthcare workers (see Other information for Standard 5.3). The following immunisations can be considered for office-based health professionals:
  • hepatitis B
  • influenza
  • pertussis
  • MMR (if non-immune)
  • varicella (if seronegative).
Whether staff have been vaccinated, have refused vaccination or have any natural immunity, this should be recorded in each staff member’s personal file. It cannot be assumed that staff will seroconvert post immunisation (for example, hepatitis B). It is therefore recommended that post-immunisation status is serologically confirmed where possible, and further vaccination provided as required. Post-immunisation immunity, where known, should also be documented in staff personal files.
▶ I. Our practice team can explain how patients are educated in respiratory etiquette, hand hygiene and precautionary techniques to prevent the transmission of communicable diseases. Your health service’s clinic team can explain how they educate or 
show patients how they can minimise healthcare-associated infections, such as:
  • respiratory etiquette (for example, blowing your nose and covering your mouth when you sneeze)
  • hand hygiene (for example, handwashing after toileting and before food preparation)
  • precautionary techniques to prevent transmission of communicable diseases.
If your health service caters to multi-lingual people and cultures, the use of pictures and diagrams is very effective. These can be strategically placed in the waiting rooms, consultation rooms and toilets. Staff may also need to be trained in cultural awareness and sensitivity when communicating these messages to patients and visitors. Alternatively, the use of health workers and cultural liaison officers in developing education materials and tools can also be effective.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure that the risk of healthcare-associated infections is minimised. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

Each of the service’s clinics has a designated staff member who is responsible for infection-control processes and this responsibility is documented in their job descriptions. The staff induction manual includes infection-control procedures and responsibilities of individual staff members, both clinical and non-clinical. These procedures and responsibilities include sharps injury, staff immunisation, hand hygiene, spills-kit use and location, environmental cleaning and waste management.

Staff induction and ongoing staff training, developed by a staff training needs assessment, is conducted to sustain effective infection control, and is recorded in line with Chapter 1 of the RACGP’s Infection control standards for office-based practices (4th edition). This is reinforced with memory prompts such as checklists.

Hand hygiene and cough-etiquette posters are displayed in the waiting room, reception, consulting rooms, staff offices, patient and staff toilets, staff kitchen and storerooms. Hand rubs and masks are available throughout the service for patients and staff members. Reception staff are aware of the need to place patients who may have an infection (cough, rash, diarrhoea and vomiting or obvious bleeding) in a separate room to the waiting room.

The health service has a written infection-control policy that includes:

  • immunisation for staff working in the service and how to document refusal
  • the appropriate use of standard and transmission-based precautions
  • sharps injury management, which includes the process for documenting a staff injury and who to report this to
  • blood and body-substance spills management
  • hand hygiene
  • environmental cleaning of clinical and non-clinical areas of the service
  • waste management (see Appendix A)
  • aseptic and sterile procedures for disposable instruments and/or instruments sterilised on site
  • a procedure for instrument processing, sterilisation and the servicing and validation of sterilisers
  • how to use personal protective equipment for both staff and patients.

If there are sterilisers on site, they are validated annually and the challenge load used in the validation is photographed and placed above the steriliser, with instructions that this is the maximum load that can be placed in the steriliser and guaranteed to be sterile after processing. There is both a clean and dirty sink in the steriliser area.

The staff members who use sterile equipment can explain how they ensure that it is still sterile – for example, intact packaging, expiry date.

Staff members are aware of how to dispose of clinical and general waste. There is a documented contract with a licensed contractor to dispose of clinical waste.

The consulting rooms have sharps bins attached to the walls, out of reach of children. They also have clinical waste bins clearly identified with a biohazard symbol, also positioned out of reach of children.

There is a cleaning log for both clinical and non-clinical areas, detailing which cleaning products are to be used and which areas are to be cleaned by external contractors.

The health service receives regular publications from the public health unit of the state health service and also receives urgent notifications of national and local infection outbreaks and public health alerts.

Showing how you meet Criterion 5.3.3

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Use job descriptions.
  • Maintain a policy and procedure manual.
  • Maintain guidelines in designated areas.
  • Through the use of direct observation.
  • Maintain a cleaning policy.
  • Maintain a cleaning log.
  • Show that you cover infection control in ongoing staff education programs.
  • Ensure there’s an education component in the infection-control policy.
  • Utilise staff files.
  • Make available brochures.
  • Have posters at reception.

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