INFECTION PREVENTION AND CONTROL

ANNUAL PROGRAM PLAN TEMPLATE EXAMPLE

The Mission of the Infection Prevention and Control (IPC) Program: to improve the health of our residents and clients and the communities we serve by reducing the risk of
healthcare-acquired infections. We are committed to a collaborative practice and management of IPC through the application of epidemiology across the continuum of care to
prevent any adverse outcomes, improve resident, staff, and visitor safety, and to minimize the infectious occupational hazards associated with the care delivery services provided.
Resources: The program is resourced with three full time Infection Preventionists and a General Manager reporting to the Executive for Clinical Governance, Risk and Innovation.
In addition to personnel, there are technological resources available for the department to support infection prevention and control activities. These include an electronic health
record system and data extraction tools that mine data from the records for infection control surveillance. In addition, collaboration with Resident Manager, Hospitality, Procurement,
Property, Work Health and Safety, Home Care, and other key stakeholders to aid with surveillance, case investigations, and continuous improvement work.
Surveillance activities: Infection data surveillance reporting has not been a focus for Aged Care providers in the past. However, the Victorian Healthcare Acquired Infection
Surveillance System (VICNISS) are in the process of creating and implementing an infection reporting platform specific to Aged Care. In preparation *** has created a dashboard
providing rates of infection, aiding with identifying trends. Infection Prevention and Control (IPC) Leads perform surveillance activities using this data and identify areas for
improvement activity focus. In addition, for the last 4 years *** has participated in the annual national antimicrobial prescribing survey (NAPS) as part of the commitment to
antimicrobial stewardship. Data collected provides a trend over time and benchmarks the RACFs against others within Australia. This data tool is used to aid with driving some
changes at the local RACF level. Collaboratively, the IPC Committee also review other data tools including cleaning audits, water management preventative work, and water sampling
results. All these aspects help to form the IPC program for the organization.

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 INFECTION PREVENTION AND CONTROL
ANNUAL PROGRAM PLAN TEMPLATE EXAMPLE
Program Plan
Area of Focus Evaluation (examples) Gaps (examples) Plan (examples)

Score 8

• IPC Lead reviews compliance at each outbreak and

Outbreak activity continues to • Application of COVID-19 outbreak provide education support
dominate throughout the year and due practices against other outbreaks • IPC Lead involvement for upskilling after hours
Outbreaks (gastro, ARI)
to the nature of COVID-19, seasonality coordinators and team leaders
is unpredictable. • Appropriate use of N95 masks • Continued Fit Testing and fit check programs including
support at Induction days.
• Needle left exposed after injection is • Product change to address exposed needle.
provided – creates hazard to staff • Continued education and support for site on procedure.
Occupational Needlestick injuries reported in 2023 • Staff using self-administer pens and re- • All needlestick injuries, to have incident report peer
Exposure – capping review to identify opportunities
specific to one product
needlestick injuries • Continued review of current prevention mechanisms to
ensure these continue to meet staff needs and address
any emerging issues
Antimicrobial National Antimicrobial Prescribing • Continuing use for prophylaxis for • Use the National Center for Antimicrobial Stewardship
Stewardship Survey performed annually each July “recurrent UTIs” noted recommendations for reassessment of long-term
MAC meetings held at each residence • No process to perform trial off UTI therapy
Emerging multi-resistant pathogens prophylaxis • Pilot the trial off medication with one residence where
high use is noted
with implications to residential aged
• Standardize a timeline for prn antifungal treatments to
care include gonorrhea, candida auris, be removed from the medication record if not used
carbapenemase-producing organisms within the specified time
(CPO) • IPC Lead attend MAC meetings and provide input for
long-term prescriptions following recommendations
from bullet 1 above

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 INFECTION PREVENTION AND CONTROL
ANNUAL PROGRAM PLAN TEMPLATE EXAMPLE
Area of Focus Evaluation (examples) Gaps (examples) Plan (examples)

Score 7

Transmission based Heavy focus on COVID-19 precautions, • IPC leads to assess isolation practices with each
precautions low numbers of other infectious • Inconsistency with monthly education dedicated day
compliance illnesses has resulted in staff focus • IPC Leads provide staff with “focus of the month” topics
misunderstanding of changes between • Monitoring/audit process not in place • Provide guideline reference to team lead each time an
• Australian Guidelines reference not MDRO is identified to upskill RN/ENs
COVID precautions and other
consistently used for identifying type
ARIs/gastro. of precautions to apply
Hand Hygiene below Audit tool implemented 2021 with IPC • Audits not consistently performed and • Data reviewed at every IPC Lead meeting
100% Leads compliance over-inflated • Individualized planning with IPC lead, RM, and CCC
Resident hand hygiene has not been • Staff unaware of data results • Hand hygiene assessment included with initial induction
successfully implemented for key • Resident hand hygiene not continually on commencement.
encouraged (included in CPO section) • IPC Lead assess individual auditors performance and
moments
discuss process as needed

• Resident hand hygiene prior to meals

Release of Version 1 CPO guidelines and communal activities, after
• Engage Leisure and Lifestyle team to assist with resident
for RACF from Victoria Department of toileting
hand hygiene prior to activities and meals
Health include elements of care not • No current alert on Care Manager
• Perform gap analysis and create plan of implementation
Emerging Pathogens currently in practice. Although rare in record
for gaps
– CPO • Screening of incoming residents, and
Australia, this is expected to become a • Present gaps to leadership
close contacts
global concern with minimal • Implement approved plan
• Clearance of close contact cases
antimicrobial efficacy against these • *Follow AMS plan recorded above
• *AMS program is not robust for
pathogenic organisms reducing/removing long term
antimicrobials
Infections Infection dashboard implemented • Healthcare-associated definitions not • Trending and analysis performed monthly by IPC leads.
established for RAC – pending release Data shared with RM and CCC
mid-2024 • Use trends to identify opportunities for improvement
• Use of McGeer’s definitions pending release of new
definitions from NISPAC and VICNISS collaborative

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 INFECTION PREVENTION AND CONTROL
ANNUAL PROGRAM PLAN TEMPLATE EXAMPLE
Area of Focus Evaluation (examples) Gaps (examples) Plan (examples)
• Implement audit tool to assess efficacy of cleaning
Cleaning assessments have not been • Variation in practices, education, and • Create standardized education tools for all cleaning staff
RACF Cleaning
performed for internal cleaning teams. compliance is unknown based on findings of audit

Disinfection: point of All shared equipment is required to be • No process in place to check • Identify key stakeholders to ensure wipes are
use care equipment cleaned at point of use. compliance with equipment cleaning consistently available
• New wipe packet must be dated at time of opening
• Ongoing assessment of process and frequency of new
wipes to identify cleaning practices
Water Management Some water testing results with • Ongoing surveillance needed • Engage with property team to create an audit process
legionella sp.. “other” - could be a flag • Collaborate with property team to identify all deadlegs
for potential issues • Review flushing program to ensure all sinks are included
in program such as medication room, pan room, etc.
• Property provide a quarterly report to leadership on
new strategies implemented against water testing

Score 6

• Surveillance needed to validate

• Property team to implement mitigation tool during the
strategies are applied consistently
pre-construction meeting phase
• Clear assigning and documentation of
• Identify employee who will assess the
New dust mitigation and water supervision responsibilities for
construction/renovation site during works – ensuring
intrusion strategies introduced. Plan sensitive operations, ensuring each
the mitigation strategies are followed
Construction and includes a checklist of task is closely monitored by
• Proactive investigations for construction or renovation
Renovation and designated employee and contractor
recommendations based on the level with a focus on developing a detailed document to
Community supervisors.
of dust created by a project or length address all potential risks and implement due diligence
environment (flood) • Unknown level of risks with
of time of water saturation based on for sensitive construction works
construction work both minor and
resident/staff areas impacted • Property team to use the water intrusion tool for
major
timeline to ensure water-logged area is dry or escalation
• Water intrusion process for drying out
if not
sensitive areas does not have a
timeline attached

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 INFECTION PREVENTION AND CONTROL
ANNUAL PROGRAM PLAN TEMPLATE EXAMPLE
Area of Focus Evaluation (examples) Gaps (examples) Plan (examples)
• Staff compliance with use of PPE when • IPC Leads continue to promote the use of the HALO
Shingles infection are difficult to track. in direct contact with shingles lesions document at key identified times (Infection Prevention
Impact to residents is minimal is unknown week, NAPS month, etc)
(immunity from childhood and access • Hepatitis B immunity is unknown for • Review of compliance with TBP for residents with
staff who will potentially be exposed identified shingles infections
to shingles vaccinations). However,
• Unknown how well staff understand or • Monitor of DoH website for updated “fully vaccinated”
staff demographic in younger use the HALO document for assessing information for COVID-19 and mandatory flu season
Vaccine-preventable employees may not have immunity or vaccination needs campaign
illness childhood vaccination for chicken pox • Resident vaccination status for • Use of data dashboard to continue to promote resident
Hepatitis B prevalence in Australia is shingles and pneumococcal illness is vaccinations for COVID-19 and Influenza
low (<1%). However, vaccination not readily available. • Review electronic medication records for updated
against this blood borne pathogen is • Ensuring updated vaccinations for staff pneumococcal and shingles vaccinations. Address same
and residents re COVID-19 and during MAC meetings
readily available
seasonal Influenza • Vaccine campaign to occur April (flu, COVID, shingles,
HALO document from Victoria DoH
pneumococcal, hep B, MMR, TdP, varicella) and
published in 2023 November (same vaccinations except flu)

• Resident knowledge for safe sex

practices is unknown • Provide initial education for staff in combination with
Changes with legislation to improve • Current health education for residents dignity of risk pilots
the rights of residents including dignity does not include safe sex and • IPC Lead create education material for resident
New Item: Sexual
of choice and risk extends to sexuality. prevention of STIs meetings
health and sexually
• *Residents are of an era of sexual • Identify sexual health brochures available and have
transmitted Recent studies show rapidly increasing
freedom but very little public these readily available at residences
infections (STIs) STIs in the older populations education campaigns (1960s, 1970s) • Monitor/surveille resident STIs
(gonorrhea, chlamydia, syphilis) • Misconception with condom use to • Engage with community partners (GP, PHUs) to aid with
only prevent pregnancy providing information for residents

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