12.1 Infection control
Infection control is an important aspect of quality health care. General practices have a high volume of patients coming through, of whom many are unwell and therefore may spread disease. Standard infection control precautions are universal and the best line of defence and can prevent the spread of infections among patients and team members.
Standard precautions
Standard precautions include:
- Hand hygiene
- Use of personal protective equipment (e.g., gloves, masks, eyewear)
- Respiratory hygiene/cough etiquette/ventilation measures
- Sharps safety
- Safe injection practices
- Sterile instruments and devices
General practices differ greatly in their day-to-day function and it is not possible to have a ‘one size fits all’ approach for infection prevention and control.
It's recommended practices determine risk in their own context and then decide on the appropriate course of action. Practices should regularly conduct infection prevention and control risk assessments within their facilities and ensure all team members understand their responsibilities in managing these risks.
Ventilation
Good ventilation is not the only measure to reduce the risk of airborne particles being transmitted through ventilation systems, but is part of a comprehensive package of protective measures, such as physical distancing, mask wearing, frequent hand washing, etc.
The College recommends these simple steps to help to increase ventilation in the practice and mitigate the risk of disease transmission and contamination.
Health and disability services standards
NZS 8134:2021 Ngā paerewa, the Health and Disability Services Standard, section 5; Infection prevention and antimicrobial stewardship, replaces the previous standard (NZS:8134.3:2008). It fosters continuous quality improvement (CQI) and is considered best practice for primary care. In order for the practice to document how team members are going to manage infection prevention and antimicrobial stewardship, the College recommends all practices comply with NZS/8134:2021, section 5. NZS 8134:2021is available for free download.
NB: If a practice is using reusable medical devices (RMD’s) then 4815:2006 also applies (as set out in the indicator).
New Zealand Standards allows one free download of the standard per user.
Antimicrobial stewardship is about avoiding the unnecessary use of antimicrobials, for example, antibiotics, and making sure that whenever they are used, they are used with care to minimise the risk of antimicrobial resistance. Patients, doctors, nurses and pharmacists all play an important part in antimicrobial stewardship.
The main features of section 5, Infection prevention and antimicrobial stewardship, are summarised below.
Please note, in the absence of a national antimicrobial stewardship programme, primary care is excluded adhering to 5.3, 5.4 and 5.5.4 and 5.5.5.
- 5.1: Governance is accountable for setting up IP and AMS programmes and:
- Plan is included in the strategic /other plans
- There is a pathway for reporting IP and APC to the clinical governance group
- Significant IP events are managed using the practices significant events and /or incidents reporting system
- 5.2: The IPC programme includes:
- A designated person with oversight and coordination of the IP programme
- Having a documented IP programme
- Having a suite of IP policies
- A Pandemic plan
- Education/training/ induction, relevant to role
- IP personnel involvement in: precuring RMDs, clinical policies, new building design.
- 5.5: Deliver services in a clean environment free of antimicrobial resistant organisms (NB: NZS43.4:2002 still applies)
- Safe and effective cleaning processes
- Safe and effective laundry processes
- Waste management handling
Infection control policies and procedures
NZS 8134:2021, section 5, provides a list of policies which should be included in the practice’s suite of infection prevention policies. However, there may be additional policies required depending on the services a practice provides.
Pandemic Planning
General practice will play a key role in both prevention and management of a pandemic. The outcome will revolve around preparation in these three key areas:
- preparation facilitated by using pandemic preparedness checklists
- communication strategies to disseminate information and resource provision including vaccines
- PPE and HR
Please note the requirement for an outbreak management plan i.e., an epidemic/pandemic response plan in NZS 8134:2021, section 5.
Your pandemic/epidemic response plan will need to be reviewed and updated regularly and have plans for managing each pandemic/epidemic.
The pandemic plan
The pandemic plan may include:
- Workforce management
- Environment management
- Ministry of Health guidelines /other identified reputable and agreed sites
- Stress management and wellbeing of team members
- Triage and assessment processes for suspected Covid19 cases and other acute presentations
- Case classification and reporting
- Contact identification, investigation and follow up
- Patient Information sheets
- Referrals and requests to outside providers
- Prescribing – alternate practices, for example, e-prescribing
- Repeat prescribing policy – specific to current pandemic/epidemic
- Supplier details for pandemic/epidemic medical supplies
- Situational PPE requirements for team members
- Stocktake process for PPE and pandemic specific medical supplies
- Communication plan: for team members, patients, PHO
- Process for continuous update of risk register
- Applicable resources to current pandemic
NB: The pandemic plan should link in with documented Business Continuity and Emergency Plans.
Sterilisation processes
Re-usable Medical Devices (RMDs)
If a practice is reprocessing reusable medical and surgical instruments and equipment, RMDs, AS/NZS4815:2006 sets the standard for cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and the maintenance of associated environments
This criterion captures the main requirements of AS/NZS 4815:2006 in both the evidence requirements and guidance information.
If practices require more in depth information on reprocessing reusable medical and surgical instruments and equipment, AS/NZS 4815:2006 can be purchased.
The standard for reprocessing RMDs requires:Using the correct soaking solution/medium for instruments
- Validation of the sterilization process using ‘indicators’
- Cleaning and disinfecting protocols
- Planning the work area layout and flow to prevent contamination.
Team members responsible for cleaning, disinfecting, sterilising, storing, and distributing items should be trained to ensure they can correctly perform these tasks.
Validation of the steriliser is important. The practice will need to demonstrate how the effectiveness of each sterilisation cycle is monitored, for example, printouts of every cycle, chemical indicator for every load or data logged directly to the computer.
Calibration on site should be done (and documented):
- When steriliser is first installed
- Annually
- When serviced or repaired
For the steriliser, the practice needs a record of annual and current (within the last 12 months):
- Servicing
- Calibration
- Validation
The practice will also need to provide records if the practice uses an off-site service.
Training and induction
The College has not specified training or frequency of training in favour of practices identifying which training best fits the scope of their individual practices and aligns with the NZ Standards applied to the indicators. For training recommendations, practices should consult the Ministry of Health, their PHO and/or the manufacturer/retailer of the equipment. The College will also accept correctly documented in-house training.
Training options:
- Training on how to safely operate, monitor and calibrate sterilizers/autoclaves provided through a PHO or from the retailer or manufacturer of the steriliser/autoclave.
- LearnOnline Infection prevention and control 2021.
- Training through WHO .
- An orientation - induction programme which is role specific and includes infection prevention and control, sterilisation, antimicrobial stewardship and waste management, as applicable.
12.2 Health care waste management
Health-care waste contains potentially harmful microorganisms that can infect patients, team members and the general public. Other potential hazards may include drug-resistant microorganisms which spread from health facilities into the environment.
Negative health outcomes associated with health care waste and by-products could include:
- sharps-inflicted injuries
- toxic exposure to pharmaceutical products, in particular, antibiotics and cytotoxic drugs released into the surrounding environment
- chemical burns from disinfection solutions, sterilization or waste treatment activities
- air pollution arising as a result of the release of particulate matter during medical waste incineration
- thermal burns from operating autoclaves
- injuries occurring in conjunction with open burning and the operation of medical waste incinerators
Lack of awareness about the health hazards related to health-care waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with health-care waste.
New Zealand Standard NZS 4304:2002 details how health care waste is managed. Management of some hazardous waste will require reference to other sources, for example, National Radiation Laboratory Code or controls under the Hazardous Substances New Organisms Act 1996). NZS 4304:2002 is available for free download.
Health care waste refers to all waste generated by a health care facility and includes ‘non-hazardous’, ‘controlled’ and ‘hazardous’ waste. Non-hazardous waste constitutes the bulk of waste generated and is managed in the same way as household waste. Hazardous waste requires proper handling, storage, transport and disposal to minimise risk to personnel, the public and the environment, and to prevent causing cultural or aesthetic offence.
A fundamental principle of waste management is the minimisation of waste.
Waste Management AS/NZS 4304:2002 requires the waste management policy to include processes on standard precautions and PPE as well as emergency waste management (which may also be included in your pandemic plan).
Healthcare waste policy
Healthcare waste policy and procedures should include:
- Emergency waste management
- A designated Waste Management Officer
- Standard precautions
- Consideration of Te Tiriti o Waitangi commitments (4.3.8 of the legislation)
- Segregation of waste
- Waste management procedures
- Re-use/recycle strategies
- Practice team members’ roles and responsibilities
- Relevant training and frequency of training
- Audit to check compliance against the policy
- Reflect the organisation’s size and complexity
- A policy and procedure review every two years
- Adherence to local council by-law
NB: Your practice policies/procedures, should adhere to the general structure suggested
here and the policy should be reviewed every two years.
Sharps
Puncture resistant sharps containers
There are a variety of different sharps containers, they are usually yellow, and all must have the biohazard symbol displayed on the outside of the container.
Wall hung sharps containers are to be positioned 1.5 metres from the floor to ensure they are safely out of reach to children. Bench top sharps containers should preferably be in restricted area, kept at the rear of the bench and not closer than 0.5 metres to the ends of the bench. In both instances, consider nearby chairs or furniture a child could potentially climb on to reach the sharps container.
Disposal of sharps falls into hazardous substances and are to be disposed of by an approved waste contractor.
Training and induction resources
The College has not specified training or frequency of training in favour of practices identifying which training best fits the scope of their individual practices and aligns with the NZ Standards applied to the indicators.
- The College will also accept correctly documented in-house training.
- New team members should be inducted into the practice’s processes of waste management.