Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
9123 Appendix 3
The Infection Prevention and Control Service
Vision
Infection Prevention and Control is a patient focused service and is recognised as the key
resource, developing collaborative relationships across the Canterbury Region
Purpose
To provide expert guidance and support to prevent the occurrence and spread of infection,
thereby, protecting the people of Canterbury.
Governance
The Canterbury District Health Board (CDHB) is obliged to comply with Health and Disability
Services (Safety) Act 2001. Under this act the Infection Prevention and Control (IP&C) Service is
mandated to ensure the CDHB can demonstrate compliance with the New Zealand Health and
Disability Services (Infection Prevention and Control) Standards NZS 8134.3:2008.
.
Authorised by
Issue 6: June 2012
Ref: 4811
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Review Date: June 2014
Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
1.1
Structure, roles and responsibilities
1.1.1 Infection Prevention and Control Service
The CDHB Infection Prevention and Control Service reports to the
Infection Prevention and Control CDHB Hospitals Committee (via the
divisional committees), which in turn reports to the Clinical Board via the
Chairperson.
1.1.2 Infection Prevention and Control Operational Team
The IP&C Operational Team consists of Clinical Nurse Specialists-IP&C
located at Christchurch, Burwood, Christchurch Women’s, Hillmorton,
TPMH, Ashburton and Rural Hospitals, and the Clinical Director of
Infection Prevention and Control.
The IP&C Operational Team (IP&C Team) has the prime responsibility
for managing, coordinating and documenting IP&C activities across the
divisions, liaising with the laboratory and implementing/auditing the
policies approved by the IPC CDHB Hospitals Committee. Each CNS
IP&C is responsible for the day to day management in their respective
health care facilities and report to managers in their divisional clinical
areas.
The responsibilities of the Infection Prevention and Control Operational
Team may include but is not limited to:
Provide education and promote best practice of Infection
Prevention and Control among staff who work for the Canterbury
DHB..
Provide advice via telephone/pager/email (service provided
during normal working hours, after hour’s advice by the
Microbiologist via the relevant hospital telephonist).
Develop and implement policies and procedures as required.
Monitor compliance with Infection Prevention and Control
policies and procedures (audit and feedback).
Provide advice and guidance during an outbreak.
Investigate cluster infections.
Undertake surveillance activities.
Provide Infection Prevention and Control advice and guidance for
patients and staff with multi drug resistant organisms.
Evaluate new products that may impact on healthcare acquired
infection
Provide advice and guidance for minimising healthcare acquired
infection during renovation and construction activities
Authorised by
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Ref: 4811
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Review Date: June 2014
Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
Process documentation for Blood and Body Fluid Exposure and
refer to Occupational Health for follow up of employees as
required.
1.1.3 The IP&C Operational Team Contact Details
(also available on the Intranet)
Divsion
Phone
Pager
Ashburton & Rural Health Services
28487
N/A
Burwood Hospital
99759
9104
Medical and Surgical Division (Christchurch
81062
8331
Hospital)
80083
5200
Paediatrics (Christchurch Hospital departments)
80341
8301
0275263175
Older Persons Health Specialist Service (TPMH)
66152
0272579514
Women’s and Children’s Health
85510
5069
Specialist Mental Health Service (Hillmorton)
33403
Out of normal working hours: Request the On-call Medical Microbiologist via the
hospital telephone office.
1.1.4 Infection Prevention and Control CDHB Hospitals Committee
The CDHB Infection Prevention and Control Hospitals Committee
(CDHB IP&C Hospitals Committee) is a multi-disciplinary committee
comprising membership from both internal and external stakeholders.
The committee meets regularly (at least 5 times a year) as well as forming
sub-committees for single subject policy making.
The committee meeting provides strategic direction and acts as the
interface between the divisional IP&C committees and the Clinical Board.
It advises and supports the IP&C Operational Team, recommends and
approves IP&C policies, endorses the Infection Prevention and Control
Annual Programme (IP&CAP).
The committee is responsible for advising clinical staff and administrators
of any serious IP&C problems or hazards and is responsible for interfacing
with the local public health service.
Authorised by
Issue 6: June 2012
Ref: 4811
Page 3 of 7
Review Date: June 2014
Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
1.1.5 Divisional Infection Prevention and Control Committees
Supporting this structure is a Divisional IP&C committee structure which
consists of members from within each division who discuss IP&C issues
pertaining to their hospitals. These committees will meet in accordance
with their own terms of reference. The Chair or nominated individuals
from these committees will provide feedback to the CDHB hospitals
committee. Ashburton & Rural Health Services, Burwood, Christchurch
Campus (Christchurch Hospital & Christchurch Women’s Hospital),
Specialist Mental Health Services and Older Person Health Specialist
Service have Divisional IP&C committees that hold regular meetings.
1.1.6 Infection Prevention and Control Link Representatives
Each division within the Canterbury DHB has an Infection Prevention and
Control Link representative group, comprising individuals from each
clinical area. The groups meet regularly under the direction and
leadership of the divisional Clinical Nurse Specialist – Infection
Prevention and Control. The purpose is to provide a forum and
mechanism for relevant Infection Prevention and Control information to
be relayed between clinical area and the Infection Prevention and Control
Service.
Authorised by
Issue 6: June 2012
Ref: 4811
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Review Date: June 2014
Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
1.2
Organisational Chart
Medical Officer of Health
Clinical Director
Infection Control
Community & Public Health
Christchurch Hospital
Meg/Surg (3 FTE)
(Medical/Surgical Division)
/
s
Christchurch Women’s Hospital
g
e
CNS IP & C (0.8 FTE)
(Women’s & Children’s Health)
in
itte
r /
rs
m
e
u
g
e
m
in
f N
o
Burwood Hospital
Infection Control Reps
rd
tiv
ffic
rs
CNS IP & C (0.8 FTE)
a
u
u
(Older Persons Health and Rehabilitation)
(staff in each ward/dept)
o
c
l O
r o
/ C
to
f N
B
e
a
rs
x
c
e
B
ic
o
d
g
H
f E
e
ire
a
rs
Hillmorton Hospital
D
ie
D
n
to
CNS IP & C ( 0.75 FTE)
C
h
f M
e
a
c
(Specialist Mental Health Service)
C
ie
tiv
ire
h
u
l M
a
D
C
c
e
n
x
io
Ashburton Hospital
E
is
CNS IP & C (0.75 FTE)
iv
(Ashburton Hospital & Rural Health Services)
D
The Princess Margaret Hospital
CNS IP & C (1.0 FTE)
(Older Persons Health Specialist Services)
CDHB Infection Control Committee
Key
IC Operational Group
Communication Pathways
ICN Infection Control Nurse Specialist
Authorised by
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Ref: 4811
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Review Date: June 2014
Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
1.3
Infection Prevention & Control Programme and Action Plan
The IP&C Team are responsible for developing and implementing the
Infection Prevention & Control Annual Programme (IP&CAP ) and the
Infection Prevention and Control Quality Action Plan.
The IP&CAP identifies the strategies for compliance with NZS 8134.3:2008.
The programme is endorsed by the IPC CDHB committee.
The IP&C Quality Action Plan forms the IP&C Team’s operational document which
details how the year’s objectives will be achieved.
1.4
Policies and Guidelines
The Infection Prevention and Control Service is responsible for developing
the Infection Prevention and Control policies and guidelines in Canterbury
DHB institutions.
CDHB IP&C Policies and guidelines are to be found in the following
locations:
Volume 10 – Infection Prevention & Control hard copy manual in all
clinical areas
Volume 10 on the Intranet via the Library and Manuals section
Volume 10 and other non-manual polices and guidelines on the CDHB
IP&C Intranet site
In the IP&C Service staff policy handbook distributed to all new
employees
Policies and guidelines are updated every three years based on evidence for
best practice.
1.5
Infection Prevention and Control Intranet Site
The IP&C service maintains an updated CDHB Intranet site which contains
a large amount of additional resources and information.
This includes some guidelines which are used less frequently than those
contained in this manual. .
These include but are not limited to:
Creutzfeldt-Jacob Disease (CJD)
Emerging New Infectious Disease (ENID)
Influenza Guidelines
Viral Haemorrhagic Disease
Endoscopy
Sigmoidoscopy
Authorised by
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Ref: 4811
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Review Date: June 2014
Canterbury DHB
Volume 10 – Infection Prevention and Control
The Infection Prevention and Control Service
Building, Construction and Maintenance
Pediculosis (lice)
Norovirus
Policy Owner
CDHB Infection Prevention & Control Service
Date of Authorisation
11 June 2012
Authorised by
Issue 6: June 2012
Ref: 4811
Page 7 of 7
Review Date: June 2014
