Role of the Corporate Infection
Preventionist in a Multi-Hospital
System
Maureen Spencer, RN, M.Ed., CIC
Corporate Infection Preventionist Consultant
Universal Health Services, a subsidiary of UHS of Delaware
King of Prussia, PA
www.workingtowardzero.com
[Nothing to Disclose]
Universal Health Services
• 25 acute care facilities in
Wash DC, So Carolina, Florida, Oklahoma,
Texas, Nevada, California
• A for-profit system with corporate offices in
King of Prussia, PA
• Infection Prevention is in the Quality and
Patient Safety Department
Corporate Infection
Preventionist
• An emerging role for Infection Preventionist (IP) in
multi-hospital systems
• Corporate Infection Preventionist is an adjunct to
the facility IPs
• Provides consultative and educational services
• Analyze facility-wide HAI data
• Implement infection prevention measures and
standardize practices, policies, IC Plans, risk
assessments
• Standardize IP Job Descriptions and pay scales
Key Role: Networking and
Consulting
• Due to the high workload of IPs today, it
can prevent them from networking and
attending local and national conferences
• They can feel isolated and lack a peer
support group
• The Corporate Infection Preventionist
serves as a facilitator to develop a
cohesive relationship with Quality and
Patient Safety at corporate office
Responsibilities
• Standardization of surveillance systems: UHS corporate dashboard
and NHSN data analysis
• Development of educational programs: webinar, infection control
training course and CIC prep course, annual infection prevention
summit
• Facilitate communication with monthly IP teleconferences, frequent
phone calls and consistent email communication
• Development and standardization of policies and procedures
• Collaboration with corporate Value Analysis Team on products
• Collaboration with corporate Process Improvement team
• Collaboration and participation with corporate Accreditation and
Regulatory team on Full Book Surveys (evaluate continued
readiness for TJC and CMS requirements)
• Consultation with Infection Preventionists, Quality Directors, OR
Directors, Chief Nursing Officers, C Suite (CEO/COO/CMO/CFO)
and medical staff in the development of a structured national
infection prevention program
Webinar Topics 2011-2012
 Overview of Rapid Molecular Technology and Cost
Effective Outcomes
 Working Toward Zero SSIs: “7 S Bundle”
 Overview of Dialysis and IC Issues
 Overview of Sterilization and Disinfection
 Overview of Antiseptics
 Statistics and Epidemiology: Beyond the 2 x 2 Table
 Overview of MRSA and Prevention Measures
 Overview of C. difficile and Prevention Measures
 2013 NHSN and UHS Requirements for Surveillance
Continued Readiness:
TJC and CMS
• Corporate Infection Preventionist participates
in monthly Full Book Surveys where both The
Joint Commission (TJC) and CMS standards
are reviewed at the selected hospital
• The team is comprised of IC, Quality, Risk
Management, Environment of Care and
Emergency Management, Medication Safety
Officer, Facilities and Life Safety
• Surveys are completed over a three day
period for preparation of the facility
Standards
CMS: Condition of Participation for
Infection Control
– CFR 482.42 (a)(1), (b)(1), etc
– Medicare standards – TAG A-0747 - 0756
Joint Commission Standards
National Patient Safety Goals
A Picture Speaks Louder
Than Words
 Photos of deficiencies are prepared in a
PowerPoint presentation
 Photos illustrate the citations in the final
report
 Allows the IP and other managerial staff
to use the presentation in staff meetings
to correct deficiencies and educate staff
Serve as a Resource
for the Infection Preventionists
•The Joint Commission (TJC)
•Association for Professionals in Infection Control and
Epidemiology (APIC)
•Centers for Disease Control (CDC)
•National Health and Safety Network (NHSN)
•Centers for Medicaid and Medicare Services (CMS)
•HICPAC, EPA, FDA, AAMI, ASHE, AII, IHI, AORN
How To Keep Up With
New Knowledge?
Resources for Daily Research:
www.infectioncontroltoday.com
www.sciencedaily.com (health – daily update)
www.hpnonline.com (daily update)
www.apic.org
www.ajicjournal.org/
http://www.cdc.gov/Other/emailupdates/
www.cdc.gov/hai/
www.jointcommission.org
www.shea-online.org
www.sentri7.com
www.pharmacyonesource.com
How To Keep Up
With New Knowledge?
Association of Perioperative Registered Nurses www.aorn.org
Association for the Advancement of Medical Instrumentation
www.aami.org
American Institute of Architects - www.aia.org
Quality Net http://www.qualitynet.org
Federal Drug Administration www.fda.gov/MedicalDevices
PubMed
http://www.ncbi.nlm.nih.gov/pubmed/
Morbidity&Mortality Weekly Report http://www.cdc.gov/mmwr/
IDSA http://www.idsociety.org/IDSA_Practice_Guidelines/
Facility Unit-Based Champions
(UBC)for Infection Prevention
• Unit Based Champion are selected to collaborate with the Infection
Preventionist
• Nursing Units, Environmental Services, Microbiology Lab, Surgical
Services, Emergency Department, etc. The IP decides the team
membership based on needs of facility
• Distribute educational materials on a routine basis for reinforcement
that is shared at staff meetings: newsletters, slides, eBug Bytes,
new policies or practice change
• Conduct observational studies (“secret shoppers”) for compliance
with hand hygiene and prevention measures (ex: environmental
cleaning, assessment of HAI bundles, precaution technique)
• IPs assist the UBC in preparing abstracts and posters and submit to
national conferences to highlight team work, projects, etc.
• IP analyzes data and shares results with appropriate committees
Unit Based Champions
Infection Prevention
eBug Bytes
April 2013
Western NY Infection Rates
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The overall surgical-site infection rate in upstate New York declined 7.9
percent, from 2.14 per 100 procedures in 2008 to 1.97 per 100 procedures
in 2011. Statewide, the infection rate decreased 3.2 percent, from 2.17
infections per 100 procedures to 2.10 infections per 100 procedures.
Each year, surgical-site infection rates in upstate New York hospitals as a
whole were lower, compared with statewide infection rates. The largest rate
of decline - 32.9 percent - over the period examined for surgery-related
infections occurred in Finger Lakes hospitals. The rate increased the most 10.8 percent - in Central New York.
Central line-associated bloodstream infections decreased in all upstate
regions, and the rate was lower as a whole upstate compared with the
statewide rate. In upstate New York, the central-line infection rate dropped
45.9 percent, from 2.07 infections per 1,000 days to 1.12 per 1,000 days. It
declined 42.4 percent statewide, from 2.38 infections per 1,000 days to
1.37 per 1,000 days.
Experts say that such simple steps as using checklists and ensuring
employees, including doctors, wash their hands before touching a patient
will lead to improvements..
Chinese told to change eating
habits as H7N9 fatalities rise
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•
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China asked its citizens to avoid contact with live poultry as it tries to
stem a H7N9 bird flu outbreak whose death toll rose to seven today, with
a further 17 people infected in three eastern provinces and Shanghai.
Consumers should avoid markets where poultry are butchered as
authorities increase monitoring for the new influenza strain, Feng Zijian,
head of emergency response at the Chinese Center for Disease Control
and Prevention, said in Beijing today. A vaccine is being prepared in case
the virus starts spreading from human to human, health officials said.
"Consumers should no longer pursue the kind of eating habits where they
buy fresh chickens that are butchered on the spot," Feng told reporters at
a briefing held jointly with the World Health Organization. "Stalls and
markets in cities where live poultry is being butchered need to be closely
monitored as possible venues of infection.“ Shares in Shanghai and
Taiwan fell on concern that infections may become more widespread,
with airlines leading the slump after trading resumed today following a
two-day holiday. The H7N9 infections tally rose to 24 after Chinese
authorities reported three more cases today.
PowerPoint Presentations for UBC
 Implementing AORN Recommended Practices
for Surgical Attire, 2012
 Prevention of Catheter Associated Urinary
Tract Infections
 Prevention of Central Line Infections
 Prevention of Ventilator Associated Pneumonia
 Safe Needle and Medication Handling
Practices
 Top 10 ways to prevent infection in 2013
Corporate IP surveys and
issues evaluated 2011-2012
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MRSA Screening
Immediate Use Steam Sterilization
Privacy curtains changing policy
and disposable curtain evaluation
Procedures for handling Cidex
OPA
Endoscopy cleaning and
reprocessing
CT Scan Contrast Procedures
Laryngoscope Disinfection
Surgical Attire Policy
VAP Prevention Bundle
CLABSI Bundle: standardized
central line insertion tray
Alcohol cap protectors for injection
port
CAUTI Prevention Bundle – IC
tray
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Biological Waste Management
C.difficile and PCR, Precautions,
Disinfection
State reporting and new regulations
Mandatory Flu Vaccinations
Safe Medication and Injection
Practices
Employee Vaccines and Titers
Reprocessing of Medical Devices
Standardization of Germicidal Cloths
Microfiber cloths and mops
SSI Prevention Bundle
Central Supply Service – biological
indicator logs, flash logs,
manufacturers recommendations
Dialysis procedures and equipment
disinfection
Risk Assessments
Medication safety evaluation: handling of
single use and multi-dose vials, USP ‘797’,
contrast media preparation
Reprocessing of medical equipment:
operating room, CSS, endoscopy,
radiology, labor and delivery, dialysis,
wound care, ambulatory surgery
Carbapenem-resistant Enterobacteriaceae
(CRE) and infection prevention measures
Corporate Senior Data Analyst
hired in 2012
• Manages the analysis of HAIs entered into
NHSN
• Provides consultation to facilities and IPs
• Conducts webinars and teleconferences
for training
• Trains new IPs in data systems and HAI
dashboard
Standardization of HAI
Surveillance
• Surveillance definitions – use of algorithms
• Standardized methodology for corporate
dashboard and entry of cases in NHSN
• UHS electronic medical record (Cerner)
Implementation and IC module
• Healthcare acquired conditions
(HACs) versus NHSN defined HAIs
Next Step: Calculate SIR by HAI by
facility and compare to national data from
NHSN
Reduction in Healthcare Acquired
Infections with corporate initiatives and
standardization of practices, products,
procedures
2011 - 2012
Healthcare Acquired Infections
2011- 2012
% Reduction
UHS 2012 Benchmark Infection Prevention Measures in Process
Rate
Catheter Associated UTI
(rate per Foley days)
57%
2.0
Infection Control Foley Catheter Tray and Silver
Foley Catheter, CHG washcloths
CLABSI
(rate by catheter days)
54%
0.0
VAP (rate by ventilator days)
11%
0.0
CABG SSI (overall rate by
surgical procedures)
71%
0.0
Central Line Insertion Kits, Alcohol Caps for Injection
Hub Protection, CHG washcloths, Central Line
Checklist
CHG rinse with oral care kits, VAP bundle checklist,
CHG washcloths, nebulizer cleaning procedures,
VAP rounds
MRSA screening before surgery, CHG preop
showers/cloths , Incisional sealants, CHG/alcohol
skin prep
Total Hip (overall rate by surgical
procedures)
15%
0.0
MRSA screening before surgery, CHG preop
showers/cloths , Incisional sealants, CHG/alcohol
skin prep
Total Knee (overall rate by
surgical procedures)
50%
0.0
MRSA screening before surgery, CHG preop
showers/cloths , Incisional sealants, CHG/alcohol
skin prep
C.Difficile (rate per 10,000 patient 12%
days)
MRSA (rate per 1,000 patient
days)
62%
4.0/10,000 patient days Bleach wipes and bleach disinfectant solution, Rapid
PCR Diagnostics for Early Diagnosis and
Precautions, Enhanced environmental cleaning,
cubicle curtain changes, room decontamination units
for high rates
0.4
CHG Washcloths, Pre-admission and Pre-op
Screening, Rapid PCR Diagnostics for Early
Diagnosis and Precautions
2013 Initiative
7 “S” Bundle to Prevent SSI
www.7sbundle.com
SAFETY IN THE OPERATING ROOM
SCREEN – FOR RISK FACTORS, PRESENCE OF MRSA & MSSA
SHOWERS – PRE-OP WITH CHLORHEXIDINE SOLUTION OR
BATH CLOTHS
SKIN PREP WITH ALCOHOL BASED SKIN PREPS
(CHLORHEXIDINE AND 70% ALCOHOL - IODOPHOR AND ALCOHOL)
SOLUTION TO POLLUTION IS DILUTION
CHLORHEXIDINE INCISION IRRIGATION (0.05%)
SUTURES – ANTIMICROBIAL (WITH TRICLOSAN)
SKIN CLOSURE – TOPICAL SKIN ADHESIVES OR
ANTIMICROBIAL DRESSINGS: (PHMB), SILVER, AMD
12.0
11.11
10.00
10.0
8.33
8.0
6.25
6.0
5.56
Started implementation of 7 S Bundle
4.0
No infections
in 2013 so far
2.0
0.00
0.00
0.00
0.00
0.00
Sep
Oct
Nov
Dec
Jul
Jun
May
April
0.00
March
Jan
Feb
0.00
0.0
Aug
0.90
2011
Rate
Rate = # Hospital-Acquired SSI/ 100 Procedures
One Hospital - Total Hip Surgical Site Infection Rates
7 S Bundle Implementation - 2012
IT TAKES INSPIRATIONAL LEADERSHIP
Principles of Social Learning
Theory
• Albert Bandura, PhD
– Role Modeling
– Self-Efficacy
(Unit Based Champions)
(Posters, abstracts, lectures)
• BF Skinner, PhD
– Reinforcement
– Contracting
– Reciprocity
(Consistent education, webinars, emails)
(Risk Assessments, IP Plans)
(Job Descriptions, IC Summit, IC Training
and CIC Prep Course)
Conclusion
• Corporate team approach in a multi-hospital system is an
excellent way to standardize practices, organize team work,
provide expert consultation, survey hospitals in a systematic
manner and provide inspirational leadership
• Monthly teleconferences and webinars enhance
communication and education
• Annual training summit creates a cohesive group, networking
and commitment to the infection prevention program
• Onsite surveys allow the corporate office to evaluate
compliance with evidence based practices and local and
national standards and regulations
• The Corporate IP Consultant position, under the umbrella of
Quality and Patient Safety, is an excellent resource for large
multi-hospital systems to reduce healthcare acquired infections.
THANK YOU