Preventing and controlling infection

Policies and procedures regarding standard and transmission-based precautions
Evidence that policies and procedures are easily accessible by the workforce
Observation of the workforce practising standard and transmission-based precautions
Training documents (for example, syllabus, attendance records, competency assessments) relating to standard and transmission-based precautions
Examples of improvement activities that have been implemented and evaluated to raise awareness and improve compliance with standard and transmission-based precautions
Examples of incidents relating to compliance with standard and transmission-based precautions being documented and discussed with appropriate actions taken to address identified risks or improve clinical safety
Observation of standardised signage and other forms of clinical communication informing on the need for standard and transmission-based precautions as part of patient care

National Health and Medical Research Council in collaboration with the Australian Commission on Safety and Quality in Healthcare: Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019). Developed to specifically support improved infection prevention and control in acute health settings. Provides a risk-management framework to ensure that the basic principles of infection prevention and control can be applied to a wide range of healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Modules: Basics of infection prevention and control course.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Modules: Principles of infection prevention and control course.

Hand hygiene

3.05—The healthcare service has a hand hygiene process that is incorporated in its overarching infection prevention and control program as part of standard precautions and:

Is consistent with the appropriate elements of the National Hand Hygiene Initiative, and jurisdictional requirements

Supports the workforce and consumers to practise hand hygiene

Explanatory notes

Key tasks

Define and implement a process for hand hygiene that is consistent with appropriate elements of the National Hand Hygiene Initiative and relevant state or territory requirements
Support the workforce to practise hand hygiene by:
providing access to training on hand hygiene processes
ensuring the workforce has the necessary consumables and facilities, such as alcohol-based hand sanitiser and a hand-washing sink to comply with hand hygiene processes
promoting the use of hand hygiene processes
Display promotional material in the healthcare service to support the workforce and consumers to practise hand hygiene
Encourage the workforce promote hand hygiene to consumers

Reflective questions

Examples of evidence

Australian Commission on Safety and Quality in Healthcare: What is hand hygiene? When performed correctly, hand hygiene results in a reduction of microorganisms on hands and contributes to prevention of healthcare-associated infection and improved patient safety.

Australian Commission on Safety and Quality in Healthcare: National Hand Hygiene Initiative. Part of a suite of initiatives to prevent and reduce healthcare-associated infections in Australian healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Modules: Hand hygiene (standard theory course or discipline specific course)

Australian Commission on Safety and Quality in Healthcare: Infection prevention and control resources for consumers. A series of fact sheets for consumers and carers about infection prevention and control, and common and emerging healthcare-associated infections.

Respiratory hygiene, cough etiquette and physical distancing

3.06—The healthcare service supports the workforce and consumers to practise respiratory hygiene, cough etiquette and physical distancing where relevant

Explanatory notes

Transmission of infections that are spread by droplet and airborne modes, such as influenza and severe acute respiratory syndrome, can be minimised with respiratory hygiene and cough etiquette practices, and physical distancing.

Respiratory hygiene and cough etiquette refers to the standard infection control precaution of covering sneezes and coughs to prevent infected persons from dispersing respiratory secretions into the air. Hands must be washed with soap and water after coughing, sneezing or using tissues, or after contact with respiratory secretions or objects contaminated by these secretions.

Physical distancing (or social distancing) refers to the practice of maintaining distance, usually one to two metres between yourself and others to prevent the spread of contagious diseases among people.

Links to Action 1.22 Safe environment.

Key tasks

Support the workforce and consumers to practise respiratory hygiene, cough etiquette, and physical distancing by:

providing the workforce and consumers with the resources and environment to achieve respiratory hygiene, cough etiquette and physical distancing
promoting key messages regarding respiratory hygiene and cough etiquette in the healthcare service
reviewing and adjusting the environment to maximise distance between people, for example, separating seating and furniture

How does your healthcare service support the workforce to practise respiratory hygiene, cough etiquette and physical distancing?
How does the environment in your healthcare service promote physical distancing between people moving around the service?
How does your healthcare service promote key messages regarding respiratory hygiene, cough etiquette and physical distancing to consumers in a way that is easily understood?

Processes or resources that are available to the workforce regarding respiratory hygiene, cough etiquette and physical distancing
Observation of promotional material such as posters in the healthcare service, in waiting rooms or treatment rooms; audio-visual material or brochures
Completion of training that supports the workforce to practise respiratory hygiene, cough etiquette and physical distancing and how to perform these actions correctly
Examples of documentation where respiratory hygiene, cough etiquette and physical distancing has been discussed with patients or their carer
The design of the healthcare service provides for sufficient space to maximise physical distancing where possible

Australian Commission on Safety and Quality in Health Care: Infection Prevention and Control eLearning Module: Principles of infection prevention and control course.

National Health and Medical Research Council in collaboration with the Australian Commission on Safety and Quality in Healthcare: Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019). Developed to specifically support improved infection prevention and control in acute health settings. Provides a risk-management framework to ensure that the basic principles of infection prevention and control can be applied to a wide range of healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Infection prevention and control resources for consumers. Fact sheets for consumers and carers about infection prevention and control, and common and emerging healthcare-associated infections.

Australian Commission on Safety and Quality in Health Care: Break The Chain of Infection Poster. Illustrates the chain of transmission of infection, in the context of COVID-19, and highlights measures that can be implemented to interrupt the spread of infection.

Australian Commission on Safety and Quality in Health Care: Infection Prevention and Control eLearning Module: Basics of infection prevention and control course.

Australian Commission on Safety and Quality in Health Care: COVID-19 Resources. For Australian health service organisations, healthcare professionals and consumers.

Australian Government Department of Health: Coronavirus (COVID-19) information and resources. Information about the coronavirus (COVID-19) pandemic, how to protect yourself and your family, where and when you can get vaccinated, and the current situation in Australia.

Aseptic technique

3.07—Where aseptic technique is required as part of the provision of health care, the healthcare service has processes to:

Identify procedures where aseptic technique applies

Monitor healthcare providers’ practices to ensure compliance with the healthcare service’s policies and procedures on aseptic technique

Explanatory notes

Note: This action is only applicable if your healthcare service uses aseptic technique is used in the provision of health care.

Aseptic technique is a set of practices that protect patients and healthcare providers from healthcare associated infections and protects healthcare providers from contact with blood, body fluid and body tissue.

Aseptic technique, when performed correctly will:

Minimise contamination of key sites
Protect patients from their own pathogenic microorganisms that may cause infection
Reduce the transmission of microorganisms
Maintain the sterility of equipment and key parts used for aseptic procedures.

Aseptic technique is an important patient safety strategy and is one of the key elements of standard precautions.

There are five essential principles of aseptic technique:

Sequencing, which ensures each step in the process is performed in an organised manner that prepares the clinician for the treatment and assesses and reduces risks to patient safety throughout the entire process
Environmental control, which ensures that factors in the clinical environment that can increase the risk of infection or harm throughout the procedure are assessed and minimised
Hand hygiene, which is maintained throughout the entire process, including absence of hand and wrist jewellery
Maintenance of aseptic fields. which ensures that the aseptic field and key parts or sites are protected throughout the entire process
Personal protective equipment (PPE), to protect both the clinician and the patient throughout the entire process.

Many of the work practices that form standard precautions are also required for aseptic technique. Examples include hand hygiene and the use of personal protective equipment. However, adherence to these practices individually does not constitute aseptic technique.

Prior to commencing any clinical procedure where aseptic technique is required, a risk assessment should be performed, and any identified risks should be eliminated or minimised before and during the procedure.

A person who is observing and assessing aseptic technique in the provision of care must also demonstrate that they are competent in aseptic technique prior to assessing other members of the workforce. Theoretical knowledge, or an understanding of aseptic technique alone, are not enough to ensure someone can demonstrate practical competence in aseptic technique.

Table 3: Aseptic technique competency

Someone who understands aseptic technique should be able to:	Someone who is practically competent in aseptic technique should be able to:
Use the correct terminology to describe concepts used in aseptic technique such as key sites, key parts, and micro fields Describe how to assess the risk of infection associated with a particular procedure and how to mitigate those risks Describe the correct sequence to perform each step in a procedure to maintain asepsis Describe the correct steps to take if asepsis is breached during a procedure Describe other factors that may affect asepsis, such as sterile stock storage and handling, environmental and patient factors.	Demonstrate the correct method and sequence to perform a procedure that requires aseptic technique, consistent with local policy or written procedures Maintain aseptic technique throughout the procedure Use standard precautions during the procedure, including performing hand hygiene, use of person protective equipment (PPE), safe handling and disposal of sharps and waste Demonstrate the correct steps to take if the aseptic field is breached during a procedure.

Someone who understands aseptic technique should be able to:

Someone who is practically competent in aseptic technique should be able to:

Use the correct terminology to describe concepts used in aseptic technique such as key sites, key parts, and micro fields
Describe how to assess the risk of infection associated with a particular procedure and how to mitigate those risks
Describe the correct sequence to perform each step in a procedure to maintain asepsis
Describe the correct steps to take if asepsis is breached during a procedure
Describe other factors that may affect asepsis, such as sterile stock storage and handling, environmental and patient factors.

Demonstrate the correct method and sequence to perform a procedure that requires aseptic technique, consistent with local policy or written procedures
Maintain aseptic technique throughout the procedure
Use standard precautions during the procedure, including performing hand hygiene, use of person protective equipment (PPE), safe handling and disposal of sharps and waste
Demonstrate the correct steps to take if the aseptic field is breached during a procedure.

Source: Adapted from NSQHS Standards Implementation guide for Action 3.11 Aseptic Technique (ACSQHC, 2022).

Key tasks

Identify the procedures for which aseptic technique is required. These include
- intravenous or invasive device insertion, access and maintenance
- wound dressings
- collection of clinical specimens (blood, swabs or urine)
- parenteral medication preparation
Facilitate access to training to address gaps in compliance. Training programs for aseptic technique may either be specific to individual clinical procedures or may apply to many different procedures. These programs need to incorporate all the principles of aseptic technique
Consider the appropriateness of technological advances to improve aseptic technique in practice, such as:
- equipment bundles
- sterile ‘starter’ packs.

What procedures are performed in your healthcare service that require aseptic technique?
Who performs these procedures and what types of training and competency assessment is available to the workforce?
What processes do the workforce use to support correct aseptic technique?
How does the healthcare service ensure healthcare providers routinely follow aseptic technique when required?

List of procedures and activities provided in the healthcare service where aseptic technique is required
Evidence of the assessment of workforce competence in performing aseptic technique
Training documents (for example, syllabus, attendance records, competency assessments) relating to aseptic technique, including training to reduce gaps in competence
Aseptic technique or specific procedure training that includes aseptic technique (such as wound care training), completion certificates or register for training modules undertaken by the workforce
Actions taken to reduce identified clinical risks associated with aseptic technique

Australian Commission on Safety and Quality in Health Care: Infection Prevention and Control eLearning Module: Principles of infection prevention and control course.

Australian Commission on Safety and Quality in Healthcare: Principles for aseptic technique: Information for healthcare workers. For staff who carry out aseptic technique.

National Health and Medical Research Council in collaboration with the Australian Commission on Safety and Quality in Healthcare: Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019): Section 3.1.6 Aseptic Technique. Developed to specifically support improved infection prevention and control in acute health settings. Provides a risk-management framework to ensure that the basic principles of infection prevention and control can be applied to a wide range of healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: NSQHS Standards Implementation guide for Action 3.11 Aseptic Technique. Factsheet.

Australian Commission on Safety and Quality in Health Care: Infection Prevention and Control eLearning Module: Basics of infection prevention and control course.

Invasive medical devices

3.08—Where invasive medical devices are used, the healthcare service has processes for the appropriate use and management of invasive medical devices that are consistent with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare

Explanatory notes

Note: This action is only applicable if your healthcare service uses invasive medical devices in the provision of health care.

Invasive medical devices are devices inserted through skin, mucosal barrier or internal cavity. Examples of these include intravenous devices, dental implants, catheters, curettes, podiatry forceps, or acupuncture needles.

Use of invasive medical devices during the provision of health care increases the risk of infection and provides a route for infectious agents to enter the body. Aseptic insertion and careful maintenance of devices is critical to reducing infection risk.

The current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare recommends processes for invasive medical devices. These include:

Criteria for the insertion, and selection of the best device for patient indications and purpose
Indications for the device to be left in place once inserted
Assessment of aseptic technique used at insertion and for maintenance activities
Use of evidence-based safety-engineered technology
Evaluation of how clinicians choose the most appropriate device
Physical environment issues that affect insertion and maintenance of devices
Patient monitoring activities to identify infections relating to invasive medical devices
Patient engagement and education about the use and maintenance of invasive medical devices
Indication for removal, evidence-based removal procedure and post-removal assessment of possible complications (for example, air emboli, bleeding from removal site).

Key tasks

Identify procedures where invasive medical devices are used in the provision of health care
Develop processes to support the appropriate use and management of invasive medical devices. Support the workforce to use the process for invasive medical devices where invasive medical devices are used in the provision of health care
Review incident reports relating to invasive medical devices for appropriateness, infection, referral, inconsistency or noncompliance with organisational policy, equipment failure and other adverse events

What procedures are delivered in your healthcare service that require the use of invasive medical devices?
What processes does your healthcare service use; and is management of invasive medical devices consistent with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare?
How is your workforce supported to use the procedure for the use and management of invasive medical devices?

List of the invasive medical devices in use in the healthcare service and where they are used
Documents outlining the process for appropriate use and management of invasive medical devices, including the selection, insertion, maintenance and removal of invasive medical devices
Examples of records in which use of invasive medical devices was discussed
Observation of use of invasive medical devices as per the healthcare service’s processes
Actions taken to manage identified risks with the selection, insertion, maintenance and removal of invasive medical devices

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Module: Principles of infection prevention and control course.

National Health and Medical Research Council in collaboration with the Australian Commission on Safety and Quality in Healthcare: Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019): Section 3.5.2 Invasive Medical Devices. Developed to specifically support improved infection prevention and control in acute health settings. Provides a risk-management framework to ensure that the basic principles of infection prevention and control can be applied to a wide range of healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Management of Peripheral Intravenous Catheters Clinical Care Standard. Describes best practice care for using peripheral intravenous catheters (PIVCs) - also known as 'cannulas'.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Module: Basics of infection prevention and control course.

Clean and safe environment

3.09—The healthcare service has processes to maintain a clean, safe and hygienic environment – in line with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare, and jurisdictional requirements – to:

Respond to environment risks, including novel infections

Require cleaning and disinfection using products listed on the Australian Register of Therapeutic Goods consistent with manufacturers’ instructions for use and recommended frequencies

Provide access to training on cleaning processes for routine and outbreak situations, and novel infections

Explanatory notes

Infection risks are minimised when the environment is clean and well-maintained. A visually clean and hygienic environment that is well maintained, and free of clutter and unnecessary items supports a health consumer's right to access safe and high-quality care in an environment that makes them feel safe.

Essential elements of an environmental cleaning process include developing an environmental cleaning program, which can be a complex process. As a minimum, a successful environmental cleaning program in a small healthcare service should address the following outcomes:

Relevant environmental risks are identified, assessed and responded to appropriately and as required. This could include increasing the frequency of cleaning in response to changes in rates of communicable diseases within the local community, for example COVID-19
As part of a healthcare service's overall infection prevention and control program, staff responsible for environmental cleaning are provided with training on the principles of infection prevention and control. This includes training in
the correct use of various cleaning equipment
handling and storage of cleaning solutions
the appropriate use of personal protective equipment (PPE)
A detailed cleaning schedule for the entire healthcare service describes recommended cleaning frequencies, cleaning procedures and policies, and role responsibilities of all staff. More information about developing a cleaning schedule can be found in Environmental cleaning practices in small health service organisations
Cleaning outcomes are routinely evaluated and monitored by routine auditing and action is taken where issues or risks are identified
Cleaning equipment and products are assessed for their suitability for environmental cleaning in the facility. This includes using products listed on the Australian Register of Therapeutic Goods and consistent with manufacturer's instructions for use and recommended frequencies.

Key tasks

Develop an environmental cleaning process for the healthcare service, addressing essential elements (refer to above)
Facilitate training for the workforce on the healthcare service’s environmental cleaning process
Implement the healthcare service’s environmental cleaning process and schedule
Evaluate environmental cleaning practices for compliance with policies, procedures and protocols, and measure outcomes of cleaning processes
Review position descriptions or contract specifications as part of the appraisal or contract review process, and provide feedback to the relevant person or group on achievements or areas for improvement

Reflective questions

Documented cleaning process that includes essential elements
Cleaning schedule for the healthcare service
Documented cleaning schedules and evidence of physical observation or audits that indicate that cleaning has been completed
Evidence that relevant workforce have undertaken training in infection and prevention control
Evidence that cleaning equipment and products used are listed on the Australian Register of Therapeutic Goods

Australian Commission on Safety and Quality in Healthcare: Environmental cleaning and infection prevention and control resources. Environmental cleaning is a critical element of standard precautions and should be a feature of every health service organisation’s infection prevention and control program.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Modules: Clean and safe environment course.

3.10—The healthcare service has processes to evaluate and respond to infection risks for:

New and existing equipment, devices and products used in the healthcare service

Clinical and non-clinical areas, and workplace amenity areas

Maintaining, repairing and upgrading buildings, equipment, furnishings and fittings

Handling, transporting and storage of linen

Novel infections, and risks identified as part of a public health response or pandemic planning

Explanatory notes

maintained. In particular, processes should be in place to minimise infection risks for:

New and existing equipment, devices and products used in the healthcare service
Clinical and non-clinical areas, and workplace amenity areas
Maintaining, repairing and upgrading buildings, equipment, furnishings and fittings
Handling, transporting and storing linen (if applicable)
Novel infections, and risks identified as part of a public health response or pandemic planning.

Infection risks to be considered may include:

Dust
Aerosols
Air handling
Filters and filtration
Sinks, drains and other plumbing
Water quality, biofilms and supply
Sewerage and wastewater
Infectious agents
Waste materials
Disruption of services and utilities
Patient, carer and workforce safety
Extra cleaning and reprocessing requirements for critical equipment.

Key tasks

Define and implement a process to evaluate and respond to infection risks for
- new and existing equipment, devices and products used in the healthcare service
- clinical and non-clinical areas, and workplace amenity areas
- maintaining, repairing and upgrading buildings, equipment, furnishings and fittings
- handling, transporting and storage of linen (if applicable)
- novel infections, and risks identified as part of a public health response or pandemic planning
This process should be based on a risk assessment of infection risks

How are infection risks for new and existing equipment, devices and products determined?
What processes are in place for minimising infection risks associated with maintaining, repairing and upgrading buildings, equipment, furnishings and fittings?
What processes are in place for minimising infection risks associated with linen?
What processes are in place for identifying and mitigating risks associated with novel infections, and risks identified as part of a public health response or pandemic planning?

Risk assessment of infection-risks
Process to evaluate and respond to infection risks for
- new and existing equipment, devices and products used in the healthcare service
- clinical and non-clinical areas, and workplace amenity areas
- maintaining, repairing and upgrading buildings, equipment, furnishings and fittings
- handling, transporting and storage of linen (if applicable)
- novel infections, and risks identified as part of a public health response or pandemic planning
Examples of implementation where an infection risk was identified and changes in cleaning processes were implemented

Australian Commission on Safety and Quality in Healthcare: Processes and product selection for routine environmental cleaning. Flowchart.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Modules: Clean and safe environment course.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Modules: Epidemiology and outbreaks course.

Australian Commission on Safety and Quality in Healthcare: 2021 Recommendations for the control of carbapenemase-producing Enterobacterales (2021 CPE Guide). Provides updated guidance on recommended strategies to prevent, detect and contain CPE in Australian health service organisations.

Workforce screening and immunisation

3.11—The healthcare service has a risk-based workforce vaccine preventable diseases screening and immunisation process that:

Is consistent with the current edition of the Australian Immunisation Handbook

Is consistent with jurisdictional requirements for vaccine preventable diseases

Identifies and addresses specific risks to the workforce, consumers and patients

Explanatory notes

This action protects the workforce from vaccine-preventable infections and minimises the transmission of vaccine-preventable infections in a healthcare service. It requires a documented screening and immunisation process for the workforce, including those who refuse vaccination.

A Workforce Immunisation Risk Matrix may be used to support healthcare services identify, evaluate and address risks that are relevant to the scope of the role and function of the members of the workforce. The risks for vaccine-preventable diseases may differ between healthcare services.

Table 4: Workforce Immunisation Risk Matrix

Source: NSQHS Standards Workforce Immunisation Risk Matrix (ACSQHC, 2021)

Key tasks

Develop a process to facilitate workforce immunisation for vaccine-preventable diseases. This process should:
identify specific risks to the workforce, consumers and patients, including prevalence of certain vaccine-preventable diseases and occupational risks
specify recommended and/or mandated vaccinations for the workforce based on identified risks. Ensure requirements are consistent with the current edition of the Australian Immunisation Handbook and state or territory requirements for vaccination
specify employer and employee responsibilities regarding immunisation
outline additional risk-mitigation strategies required where members of the workforce refuse, or have medical exemptions for specified vaccinations
ensure employment agreements, policies, procedures or protocols specify recommended and/or mandated vaccinations

Reflective questions

List of recommended and/or required workforce vaccinations, including rationale for inclusion
Evidence of employment agreements, policies, procedures or protocols that outline to employer and employee the responsibilities for managing occupational risks for vaccine-preventable diseases or immunisation requirements
Audit results or records of workforce vaccination compliance
Evidence of communication with prospective employees or the existing workforce about vaccination requirements
Workforce vaccination records

Australian Commission on Safety and Quality in Health Care: NSQHS Standards Workforce Immunisation Risk Matrix. Used by health service organisations to assess their workforce for risks associated with vaccine preventable disease transmission and develop actions to mitigate these risks.

Australian Government Department of Health: Australian Immunisation Handbook. Provides clinical guidelines for healthcare professionals and others about using vaccines safely and effectively.

Australian Commission on Safety and Quality in Health Care: Infection Prevention and Control eLearning Module: Health workforce screening and immunisation for vaccine-preventable diseases.

Infections in the workforce

3.12—The healthcare service has risk-based processes for preventing and managing infections in the workforce that:

Are consistent with the relevant state or territory work health safety regulation and the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare

Align with state and territory public health requirements for workforce screening and exclusion periods

Manage risks to the workforce, patients and visitors, including for novel infections

Promote non-attendance or remote-attendance at work and avoiding visiting or volunteering when infection is present or suspected

Plan for, and manage, ongoing service provision during outbreaks and pandemics or events where there is increased risk of transmission of infection

Explanatory notes

This action aims to minimise the risks of transmission of acute infections via workers, patients and visitors as well as disruptions to health service delivery where healthcare providers are unable to practise due to suspected acute transmissible infections. Processes should be risk-based and applicable in response to outbreaks and pandemics. In some instances, physical distancing and screening of staff and visitors may be appropriate.

While the healthcare service has a duty of care to the workforce, staff members also have a responsibility to protect themselves and to not put others at risk.

The healthcare service should identify or develop policies, procedures or protocols that respond to areas in which there is the greatest risk of infection transmission. Development of policies, procedures or protocols should include consultation with the workforce and relevant key stakeholders where risks have been identified, where changes need to occur or improvements can be made to respond to risks, and consider:

Identification of possible cases
Implementation of other treatment options (for example, rescheduling procedures)
Exclusion periods for elective services
Suggested management options for suspected or confirmed infections that may be transmissible
How impacts on treatment and recovery are minimised
Workforce occupational risk.

Policies should be incorporated in workforce orientation and training programs to include key aspects of standard and transmission-based precautions. Evaluate attendance at, and content of, the orientation or induction programs for the workforce.

Key tasks

Define and implement a process for preventing and managing infections in the workforce. This should include:
- circumstances where members of the workforce should refrain from attending the healthcare service and interacting with patients, for example when an infection is suspected or confirmed, or when at greater risk of infection or susceptible to adverse health outcomes
- whether healthcare providers are able to work via remote-attendance and how this will be facilitated
- if and how service provision will continue during periods of outbreaks and pandemics, or events where there is increased risk of transmission of infection is common, for example, seasonal influenza or local outbreaks of viral gastroenteritis.
- how the healthcare service will access or be alerted to local state or territory public health orders or guidelines for the requirements for workforce screening and exclusion periods
Provide the workforce with training on managing exposure to infections

Reflective questions

Examples of evidence

National Health and Medical Research Council in collaboration with the Australian Commission on Safety and Quality in Healthcare: Australian Guidelines for the Prevention and Control of Infection in Healthcare – Section 4.2 (2019). Developed to specifically support improved infection prevention and control in acute health settings. Provides a risk-management framework to ensure that the basic principles of infection prevention and control can be applied to a wide range of healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Healthcare: Infection Prevention and Control eLearning Module: Preventing and managing occupational exposures to infectious agents in health care course.

Australian Government Department of Health: Communicable Diseases Network Australia – Series of National Guidelines (SoNGs). Provide nationally consistent advice and guidance to Public Health Units to help them respond to notifiable diseases using best practice.

Australian Government Department of Health: Local state and territory health departments

Reprocessing of reusable medical devices

3.13—Where reusable equipment, instruments and devices are used, the healthcare service has:

Processes for reprocessing that are consistent with relevant national and international standards, in conjunction with manufacturers’ guidelines

A process for critical equipment, instruments, and devices that is capable of identifying the:
patient

procedure

reusable equipment, instruments and devices that were used for the procedure

Processes to plan and manage reprocessing requirements and additional controls for novel and emerging infections

Explanatory notes

Note: This action is only applicable if your healthcare service uses critical reusable equipment, instruments and devices in the provision of health care.

Where reusable equipment, instruments and devices are used, the healthcare service must minimise infection risks to patients and the workforce by ensuring adequate identification of, and procedures for reprocessing reusable medical equipment. This includes cleaning, disinfection and sterilisation of reusable medical devices, equipment and instruments used, as well as process and records to identify the patient, procedure and reusable equipment, instruments and devices that were used.

Critical medical equipment, instruments and devices are items that confer a high risk for infection if they are contaminated with microorganisms, and must be sterile at the time of use. They include any objects that enter sterile tissue or the vascular system, because any microbial contamination could transmit disease.

Healthcare services must ensure that processes for reprocessing are consistent with the relevant Australian Standard. Where multiple Australian Standards may be applicable, the healthcare service should adhere to the standard most appropriate for their service context.

In developing processes for reprocessing, consider:

Whether the healthcare service has the facilities and the ability to reprocess the required reusable equipment, instruments and devices on site?
Whether sterilising services should be centralised or shared with another service?
Are specialised reprocessing techniques required for some reusable medical devices (for example, low-temperature sterilisation or ethylene oxide) and are processes in place to achieve this?
Could the purchase of commercial, pre-sterilised single-use items help to meet the healthcare service’s needs?
Could an external sterilising service be contracted to provide reprocessing services for critical equipment, instruments or devices? See the Australian Guidelines for the Prevention and Control of Infection in Healthcare for a description of critical items.
If services are contracted, are contract development, documentation and record keeping conducted in consultation with key groups, including:
an identified position with responsibility for the service’s sterilising
- senior management
- the clinical workforce
- consumer representatives.

If reprocessing of reusable equipment is to be carried out on-site, policies, procedures and protocols should include:

Ensuring the environment and infrastructure consists of enough dedicated space to safely carry out all the required steps for reprocessing
Maintenance and replacement schedules for reprocessing equipment
Appropriate storage to maintain the integrity of reprocessed equipment, instruments and devices before use, in all areas where they are stored
Decontamination and safe packaging for transporting reusable equipment, instruments and devices from clinical areas that may be located away from the sterilising services
A process for fault or variance reporting that includes responsibility, actions and risk management strategies
Document control and record-keeping processes that allow data to be retrieved at any time
Environmental controls, including water quality, air handling, access, maintenance schedules and cleaning activities
Consumables, including packaging materials and personal protective equipment
Suitably trained members of the workforce who are available for sterilising services, and wherever decontamination of used reusable equipment, instruments or devices is undertaken
Use of an incident management and investigation system to report any incidents relating to the reprocessing of reusable equipment, instruments and devices. Review the incident management and investigation system in the healthcare service to identify any variation between practice and policy, procedure or protocol, and act to rectify the risks.

Key tasks

Identify the healthcare service’s need for reusable critical equipment, instruments and devices
Develop and implement a process for reprocessing of reusable critical equipment, instruments and devices used in the healthcare service. This process must:
- be consistent with the relevant Australian Standard and manufacturer’s instructions
- describe how the healthcare service will record and identify (if required) the patient, procedure and reusable equipment, instruments and devices that were used for the procedure
- identify situations when processes may need to be reviewed
- determine how additional controls for novel and emerging infections may be identified and incorporated

In some instances, these processes may also be required for the reprocessing of semi-critical equipment, in accordance with the relevant Australian Standard - for example, where high-level disinfection of a semi-critical medical device is required.

Is there a process for identifying and registering the reusable equipment, instruments and devices that need to be reprocessed?
How does your healthcare service ensure that reprocessing of reusable medical equipment, instruments and devices follows relevant standards and manufacturers’ instructions?
How does your healthcare service identify which reusable equipment, instruments and devices have been used during the care of a patient?
What mechanism does your healthcare service have in place to recall those patients at risk of acquiring an infection as a result of the reusable equipment, instruments and devices used?
How are the sterile stock and reprocessed equipment, instruments and devices transported, stored and maintained?

Policies, procedures and/or protocols for processing reusable equipment, instruments and devices that are consistent with relevant national or international standards and manufacturer’s instructions for use
Examples of agreements or contracts in place to manage reprocessing services, that include safety and quality measures such as incident and performance monitoring
A register of reusable medical devices
Access to, or copies of, manufacturer’s instructions for each device
Records of sterilisation that verify instrument reprocessing is consistent with relevant national or international standards
Maintenance schedules for equipment used to reprocess medical equipment, reusable instruments and devices are monitored and reviewed
Registers of staff training and competency assessments
Audits to ensure the integrity of sterile stock integrity and supply
Relevant documentation where reports on cleaning, disinfection and sterilisation processes are reviewed and discussed
Risk assessments where there are deviations in the requirements of relevant standards and the manufacturer’s instructions
Policies or procedures that specify which procedures should be used for single-use items
Policies or procedures for the use of reusable items that reflect relevant risk management strategies to ensure safe clinical practice and determine when, for which procedures and/or where reusable items should be used
Register or record of patients who have had procedures using reusable equipment, instruments and devices

National Health and Medical Research Council in collaboration with the Australian Commission on Safety and Quality in Healthcare: Australian Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) Section 3.1.4 Reprocessing of reusable medical devices. Developed to specifically support improved infection prevention and control in acute health settings. Provides a risk-management framework to ensure that the basic principles of infection prevention and control can be applied to a wide range of healthcare settings.

Australian Commission on Safety and Quality in Healthcare: Addendum NSQHS Standards Accreditation Workbook 2021 Infection Prevention and Control Standard. Provides users with updated information on reflective questions and examples of evidence for the 2021 Preventing and Controlling Infections Standard within the National Safety and Quality Health Service (NSQHS) Standards. Principles and strategies are broadly applicable.

Standards Australia: Catalogue of Australian Standards. Standards Australia is the nation's peak non-government, not-for-profit standards organisation.

Antimicrobial stewardship

3.14—The healthcare service that prescribes, supplies and/or administers antimicrobials:

Provides healthcare providers with access to, and promotes the use of, current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing

Incorporates core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard into service delivery

Supports healthcare providers who prescribe antimicrobials to review compliance of antimicrobial prescribing against current local or Australian therapeutic guidelines

Supports healthcare providers to identify the areas of improvement and takes action to increase the appropriateness of antimicrobial usage

Has mechanisms to educate consumers about the risks, benefits and alternatives to antimicrobials for their condition

Explanatory notes

Note: This action is only applicable if your healthcare service prescribes, supplies and/or administers antimicrobials.

Inappropriate use of antimicrobials contributes to the emergence of resistant bacteria and causes patient harm. Patients with antimicrobial-resistant infections are more likely to experience ineffective treatment, recurrent infection, delayed recovery or even death. Antimicrobial stewardship (AMS) is a coordinated set of strategies to improve the appropriateness of use and minimise the adverse effects of antimicrobial use.

The Antimicrobial Stewardship Clinical Care Standard provides guidance to healthcare providers and services on delivering appropriate care regarding antimicrobials. It includes eight quality statements:

A patient with a life-threatening condition due to a suspected infection receives an appropriate antimicrobial immediately, without waiting for the results of investigations
When a patient is prescribed an antimicrobial, this is done in accordance with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines and the antimicrobial formulary
When an adverse reaction (including an allergy) to an antimicrobial is reported by a patient or recorded in their healthcare record, the active ingredient(s), date, nature and severity of the reaction are assessed and documented. This enables the most appropriate antimicrobial to be used when required
A patient with a suspected infection has appropriate samples taken for microbiology testing as clinically indicated, preferably before starting antimicrobial therapy
A patient with an infection, or at risk of an infection, is provided with information about their condition and treatment options in a way that they can understand. If antimicrobials are prescribed, information on how to use them, when to stop, potential side effects and a review plan is discussed with the patient
When a patient is prescribed an antimicrobial, the indication, active ingredient, dose, frequency and route of administration, and the intended duration or review plan are documented in the patient’s healthcare record
A patient prescribed an antimicrobial has regular clinical review of their therapy, with the frequency of review dependent on patient acuity and risk factors. The need for ongoing antimicrobial use, appropriate microbial spectrum of activity, dose, frequency and route of administration are assessed and adjusted accordingly; investigation results are reviewed promptly when they are reported
A patient having surgery or a procedure is prescribed antimicrobial prophylaxis in accordance with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines. This includes recommendations about the need for prophylaxis, choice of antimicrobial, dose, route and timing of administration, and duration.

Key tasks

Ensure healthcare providers have access to, and promote, current guidelines for treatment and prophylaxis for common infections relevant to the patient population, the indications for use and the local antimicrobial resistance profile (if known). Information sources include:
- Therapeutic Guidelines: Antibiotic, one of the key national guidelines for antimicrobial prescribing in Australia.
- Health Pathways in a healthcare service’s local Primary Health Network
- Local evidence-based guidelines, where available
Support healthcare providers to incorporate relevant core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard, developed by the Commission
Review policies, clinical pathways, point-of-care tools and education programs to ensure that they incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard
Collect and regularly review data on antimicrobial against the therapeutic guidelines or local pathways. Indicators specified in the Antimicrobial Stewardship Clinical Care Standard may be helpful
Use this analysis to identify areas for quality improvement and action to be taken
Provide access to and promote resources to educate consumers about the risks, benefits and alternatives to antimicrobials for their condition

How do healthcare providers access current Therapeutic Guidelines or evidence-based, locally endorsed guidelines at the point of care?
How are healthcare providers supported to incorporate core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard?
What information is communicated to patients when an antimicrobial is prescribed, supplied or administered? How is this information communicated?
How is data on antimicrobials collected, reviewed and used for improvement action?

Observation of healthcare providers accessing electronic or printed copies of endorsed Therapeutic Guidelines: Antibiotic
Examples of communication materials provided to patients regarding antimicrobials
Guidance for healthcare providers on providing materials to patients regarding antimicrobials
Requirements for and/or records of healthcare providers completing NPS MedicineWise antibiotic prescribing modules.