STH Infection Protection and Control Team Policies and Guidelines Review Schedule (as of 29 th Jan 14 )
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1 STH Infection Protection and Control Team Policies and Guidelines Review Schedule (as of 29 th Jan 14 ) G5 E Policy/Document Start Review Review to be Competed Current Status Equality Impact Analysis Lead Reviewer General Infection Prevention and Control IPC Standard Precautions, Prevention of Sharps Injuries and Prevention of Exposure to Blood and Body Fluids - Standard (Universal) Infection Control Precautions - Management of Sharps Spillage, Safe Handling of Sharps, Safe Disposal of Sharps, Sharps Generated by Patients at Home, Safety Devices - Prevention of Occupational Exposure to Blood Borne Viruses [BBVs], Including Prevention of Sharps Injuries May 15 Jul 15 Current Current Sandi Carman/Patty Hempshall/Helena Parsons/ Chris Morley Hand Hygiene Policy Oct 14 Jan 15 Current Current Rachael Duckworth Aseptic Technique Oct 14 Jan 15 Current Current Rachael Duckworth Care of the Deceased Patient see also Trust Last Offices Policy Aug 14 Nov 14 Current Current Andy Garner Patient Placement, Isolation Protocols, Ward Closure and Outbreak Management Major Outbreaks of Communicable Infection - Outbreak Control Plan Jul 16 Oct 16 Current Current Christine Bates Closure of Wards, Departments and Premises to New Admissions Infection Control Isolation Precautions and Patient Placement Guidelines Dec 15 Mar 16 Current Current Patty Hempshall Closure of Beds Due to Outbreak/Infection Control Concern Jul 15 Oct 15 Current Current Rachael Duckworth Equipment, Devices, Environment etc. related policies/guidance Linen Guidelines New Waste - see Trust Waste Strategy and Policy Unknown Computer Keyboards & Equipment Cleaning Guidelines Final draft out for comment Waste Manager Final draft out for comment Waste Manager Bev Wade Rob Green Feb 16 May 16 Current/ Current Julie Parker
2 Decontamination of Hospital Equipment and Medical Devices Policy Decontamination Policy (see Section 3 of the Infection Control Guidelines) Jul 10 Sep 10 Review Underway Review underway (D) Christine Bates Jul 08 Sep 08 Review underway Review underway (D) Christine Bates/Joyce Linskill/Patty Hempshall Invasive Procedures Bladder Management and Catheterisation Policy for Adults Infection Control Guidelines for Central Venous Catheters (CVC) - including PICC and long lines - Sep 15 Bladder Care Team Bladder Care Team Shelagh Whitaker May 16 Jul 16 Current Current David Partridge Taking Blood Cultures Procedure Sep 15 Dec 15 Current Current Peripheral IV Policy Sep 14 Dec 14 Current Current Christine Bates/Liz McLellan Bev Wade/Dave Partridge/Helena Parsons Antimicrobial Prescribing Antibiotic Review Policy Feb 13 May 13 Current Antibiotic Prescribing Guidelines Aug 13 Nov 13 Current Restricted Antibiotic Policy May 13 Jul 13 Current Current Chest Infection & Pneumonia Guidelines Aug 13 Nov 13 Current Antimicrobial Therapy Team Antimicrobial Therapy Team Antimicrobial Therapy Team
3 Specific organism policies/guidance Diarrhoea related policies/guidance Suspected Infective Diarrhoea Jul 15 Oct 15 Current Current Rachael Duckworth Norovirus Nov 14 Feb 15 Current Current Patty Hempshall/ Laura Prtak Clostridium difficile Clostridium difficile Associated Diarrhoea Protocol for the Management of Adult Patients Clostridium difficile toxin [CdT] Nursing Care Guideline Clostridium difficile carriage [CdT] Nursing Care Guideline Protocol for use of Faecal Transplant in the management of Clostidium difficile disease at STH Jun 16 Aug 16 Current Current Helena Parsons Sep 16 Dec 16 Current/ Updated version awaiting uploading by CJ Current/ Updated version awaiting uploading by CJ Rachael Duckworth Sep 16 Dec 16 Current Current Rachael Duckworth Dec 14 Mar 15 Current Current Helena Parsons/Dave Partridge
4 Other organisms Meticillin-Resistant Staphylococcus Aureus (MRSA) Guidelines Transmissible Spongiform Encephalopathies Creutzfeldt-Jacob Disease [CJD] and Related Disorders: Safe Working and the Prevention of Infection Glycopeptide Resistant Enterococci Guidelines for the Control of Glycopeptide Resistant Enterococcus [GRE] in Hospitals (also known as Vancomycin Resistant Enterococcus or VRE) Jul 10 Oct 10 Final draft Final draft Kim Tomlin Sep 16 Dec 16 Current Current Christine Bates Dec 14 Mar 15 Current Current Carbapenem Resistant Gram Negative Policy Mar 16 Jun 16 Current/ Current Control of Tuberculosis, including MDRTB Tuberculosis an Integrated Policy for the Control of TB in Sheffield Respiratory Viruses Severe Acute Respiratory Syndrome [SARS], Human Cases of Avian Infuenza Policy and SRINIA Jun 12 Sep 12 (see comment) Current (review delayed until mid 2013 whilst HPA reconfigures) Draft IPC sections out for comment Current Helena Parsons/Liz McLellan Helena Parsons/Patty Hempshall Suzanna Mathews Sep 15 Dec15 Current Current Christine Bates Influenza and other respiratory viruses New New Review Underway Review Underway Raza Mohammed Viral Haemorrhagic Fevers Dec 12 Mar 13 Current/Under review Current/Under review Alison Cope Anthrax Management and Control of Anthrax Dec 14 Mar 15 Current Current Christine Bates Smallpox Current/Draft Alison Cope Sep 13 Dec 13 Current/Draft underway Management and Control of Smallpox underway Christine Bates Chickenpox Aug 15 Nov 15 Current Current Mohammed Raza Scabies Aug 14 Nov 14 Current Current Rachael Duckworth Lice/Fleas/Bed bugs Mar 15 Jun 15 Current/Final draft Current/Final draft being prepared being prepared Andy Garner
5 Occupational Health related policies/guidance Management of Healthcare workers with Infections Management of Occupational Exposure to Blood Borne Viruses [BBVs] and Post-Exposure Prophylaxis Oct 11 Jan 12 Review Underway Sep 11 Dec 12 Current To be produced at next review To be produced at next review Bev Wade Occupational Health/Virologist Water Related policies/guidelines Control and Management of Water Quality and Ventilation Systems (includes Water Safety Policy and Legionella Control & Management) Jan 16 Apr 16 Current Current Regular flushing of taps Sep 15 Dec 15 Current Current Liz McLellan/Legionella Committee Liz McLellan/Legionella Committee Birthing Pools Nov 15 Feb 16 Current Current Liz McLellan Hydrotherapy pools Jun16 Aug 16 Current Current Liz McLellan Drinking Water Coolers Aug 15 Nov 15 Current Current Liz McLellan Ice Machines Aug 15 Nov 15 Current Current Liz McLellan/Patty Hempshall Other Infection Control Related Policies and Guidelines Completing Death Certificates in Respect of Current Jan 15 Apr 15 MRSA, C. difficile and Other HCAI Current Christine Bates Animals and Pets in Hospital Aug 14 Nov 14 Current Current Chris Morley Statutory Notification of Infectious Diseases and Reporting of Healthcare Associated Diseases and Aug 14 Nov 14 Current Current Christine Bates Infection Related Serious Untoward Incidents Invasive Meningococcal Disease Guidance for Health Professionals in South Yorkshire N/A N/A HPA HPA Rosie McNaught
6 Current Infection Control Guidelines Manual Infection Control Guidelines (Sections to be divided up into separate policies many listed above) Section 1 Superseded Section 2 Superseded Section 3 Under review Section 4 Superseded Section 5 Superseded Section 6 Superseded Patty Hempshall awaiting decontamination policy review IPC Service Documents STH IPC Strategy Nov 15 Feb 16 Current Current Christine Bates The Structure of the IPC Service for the STH Nov 15 Feb 16 Current Current Christine Bates Procedure for the Production of the Trust-wide IPC Programme Nov 15 Feb 16 Current Current Christine Bates DIPC Job Description Oct 15 Jan 16 Current N/A Christine Bates DIPC Personal Specification Oct 15 Jan 16 Current N/A Christine Bates Infection Control Accreditation Programme and Draft out for comment Draft out for comment Jun14 Sep 14 Audit Tools Patty Hempshall Key for Status of Policy/Guidance: Review required = Document requires review but this has not commenced to date Review underway = Document under review by IPC Team Draft for comment = Document reviewed and out for comment by IPC Team Final draft = Document reviewed and final draft being produced following review by IPC Team Awaiting Approval = Document complete, Reviewed by IPCT, awaiting IPC Committee Approval Awaiting Ratification = Document complete, Reviewed by IPCT, Approved by IPC Committee, awaiting TEG Ratification Awaiting Publishing = Document Reviewed, Approved and Ratified, awaiting Publishing by Document Control Team Current = Document Reviewed, Approved and Ratified and Published on Trust Intranet Key for Status of Equality Impact Analysis To be completed as part of document development of review To be produced at next review = No initial EIA produced as yet but will be part of next review of document Review required = Initial EIA produced and published, now out of date and requires review as part of the document review Review underway = EIA under review by IPC Team as part of document review
7 Draft for comment = EIA reviewed and out for comment by IPC Team as part of document review Final draft = EIA reviewed and final draft being produced following review by IPC Team as part of document review Awaiting Approval = EIA complete, Reviewed by IPCT, awaiting IPC Committee Approval as part of document review Awaiting Uploading = EIA complete, Reviewed by IPCT, Approved by IPC Committee, awaiting uploading on to the Equality and Diversity website by Sue Coulson Current = EIA Reviewed, Approved and Ratified and Published on Trust Intranet G5
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AND FOLLOWING EXPOSURE TO Page 1 of 9 This Policy applies to all staff employed by NHS Greater Glasgow & Clyde and locum staff on fixed term contracts and volunteer staff. Policy Objective To prevent Healthcare
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The most up-to-date version of this policy can be viewed at the following website:
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