Policies and guidelines

This Policy Directive outlines the mandatory infection prevention and control requirements for NSW Health organisations (including inpatient, outpatient, outreach).

The scope of this Policy Directive includes:

• Requirements for the infection prevention and control program
• Direction on governance
• Infection prevention and control incidents and risk
• Quality monitoring (surveillance)
• Standard and transmission-based precautions
• Strategies for the prevention and management of HAIs including those caused by multidrug-resistant organisms (MROs) and communicable diseases
• Outbreaks of transmissible infections and communicable diseases
• Reprocessing of reusable medical devices
• Handling of animals within healthcare settings
• Environmental sustainability.

• Infection Prevention and Control in Healthcare Settings Policy

This New South Wales (NSW) Healthcare Associated Infection (HAI) Clinical Indicator Manual outlines the minimum level of HAI surveillance that NSW public healthcare organisations (PHO) providing acute care services are to undertake. The Manual was developed in consultation with NSW local health districts (LHDs) and specialty health networks (SHNs) to provide healthcare facilities with a framework to conduct HAI surveillance activities in key areas of increased risk.

The goals of NSW HAI Surveillance are to:

• Ensure appropriate clinical indicators are collected and reported in keeping with national and international recommendations
• Ensure all NSW public healthcare organisations use standardised definitions and methodology
• Ensure the data is valid and robust.

All facilities are expected to review their own data to identify issues and act on these in a timely manner.

The NSW HAI Clinical Indicator Manual contains the technical information to allow standardised definitions and methodology for surveillance personnel who are collecting and reporting data to the NSW Ministry of Health.

Practices recommended in this manual are based on the expectation that PHOs have at least basic infection prevention and control systems in place and adequate resources for surveillance, data collection, analysis and reporting.

To enable the CEC to better understand issues identified during the implementation of the Manual, this issues log has been developed for you to provide your feedback and suggestions on how the issue can be resolved. We welcome feedback on issues related to interpretation, collection, investigation, reporting and validation of the HAI Clinical Indicators. We will monitor the issues log regularly. Please click here.

• HAI Clinical Indicator Manual

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Tools to support implementation

• Central Line Associated Blood Stream Infection Validation Check List – Adults
• Staphylococcus aureus Blood Stream Infection Validation Check List – Adults
• Vancomycin-resistant Enterococcal Blood Stream Infection Validation Check List – Adults
• Tool to Assess Severity of C. difficile Infection
• Surgical Site Infection Case Validation Check List
• Central Line Days tally tool

This Guideline is designed to assist public health care facilities in NSW to:

1. Identify suspected cases of Carbapenemase producing Enterobacterales (CPE)
2. Implement control measures to prevent transmission of CPE
3. Understand the local epidemiology of CPE.

While this Guideline has been written specifically for CPE, recommended measures may also be applicable to any species of multidrug-resistant Enterobacterales (MDR-E) and other carbapenemase producing organisms (CPO). The local decision whether to apply to other MDR-E and CPO is to be made in consultation with content experts. As evidence for recommendations continues to emerge, recommendations will be reviewed and revised when significant new findings are available.

• Surveillance and Response for Carbapenemase-Producing Enterobacterales (CPE) in NSW Health Facilities

The purpose of the NSW Health Intravascular Access Device (IVAD) Infection Prevention and Control Policy is to provide guidance to NSW Health Organisations (HO's) including Affiliated Health Organisations on the minimum standards for insertion, management and removal of IVADs, in order to minimise the adverse health impacts on patients and reduce burden of healthcare associated Infections (HAIs). This Policy is to be read in conjunction with NSW Health Infection Prevention and Control Policy.

• Intravascular Access Devices (IVAD) - Infection Prevention & Control

This Guideline has been developed to support NSW public healthcare facilities with effective and timely escalation of information on outbreaks or clusters of healthcare associated infections, multidrug-resistant organisms (MROs) and/or non-MROs.

• GL2019_013: Triggers for Escalation Following Detection of Infection Outbreaks or Clusters