Hospital Patient
Safety Initiatives:
Infection Control
Michele Kala, RN
October 2011-Developed by CMS
• Related to three Conditions of Participation
(CoPs)
– 482.21 Quality Assessment and Performance
Improvement (HFAP Hospital Chapter 12)
– 482.42 Infection Control (HFAP Hospital Chapter
7)
– 482.43 Discharge Planning (HFAP Hospital Chapter
15)
Worksheet Purpose
• Reduce hospital acquired conditions (HAC)
including hospital acquired infections (HAI)
and preventable readmissions.
• Designed to assist surveyors and hospital staff
to identify when and where compliance is an
issue.
CMS Worksheet Development
• In draft form until midyear 2013
• There may be additional adjustments to the
worksheets
• Currently in use by state surveyors and
accrediting agencies.
CMS Worksheets:
• Facilitate recording of observations by
surveyors
• Are a self-assessment tool
Findings
• Hospitals with higher readmission rates may
be at greater risk for noncompliance with all
three CoPs.
• The tools assist facilities in focusing on key
issues that impact positive patient outcomes
and thereby compliance.
Verification Methods
• Interview
• Observation
• Topic Specific Document Review
• Medical Record Review
• Other Document Review
Hospital Patient Safety Initiatives
• Quality Assessment and Performance
Improvement
• Infection Control
• Discharge Planning
Infection Control Worksheet
Five Sections
1. Infection Prevention
2. General Elements
3. Equipment Reprocessing
4. Tracer Patient
5. Special Care Environment
1. Infection Prevention
• Prevention Program
• Infection Control Quality Systems
• Multiple Drug Resistant Organism (MDRO)
Program and Antibiotic Stewardship
a. Prevention Program & Resources
1. A designated Infection Control Officer (ICO)
2. Qualifications of ICO
3. Practice and policies based on nationally
recognized standards
4. Infection Control Risk Assessment related to
construction
5. Air exchange rates
Construction Risk Assessment
www.premierinc.com/quality
– Tools and Resources
– ICRA Matrix
– Matrix of Precautions for Construction and
Renovation
www.ashe.org
– ICRA Matrix
Air exchange rates
Airborne Infection Isolation Room (AIIR)
•
Existing construction6 air exchanges per hour, OR
•
New construction or renovation –
12 exchanges per hour, OR
•
Per state licensure rules, if more stringent.
Air exchange rates (cont’d)
• Direct exhaust to the outside, or recycled
through a HEPA filter
• Daily monitoring of pressure with visual
indicators.
• Door is closed
b. Hospital Quality Systems Related to
Infection Prevention and Control
1. IC Problems are Identified and Addressed
2. Non-punitive Approach to Reporting
3. Leadership Support
4. Infection Control Risk Assessment
Infection Control Risk Assessment:
References
• Infection Control Risk Assessment
APIC 2011-Baltimore (Web search)
• www.infectionpreventiontools.com
SPMH Risk Assessment
c. Prevent MDROs and Promote
Antibiotic Stewardship, Surveillance
1. Policies to minimize transmission of Multiple
Drug Resistant Organism (MDROs)
2. Facility MDRO policy effectiveness:
identification process preventing
development and transmission of MDROs
c. Prevent MDROs and Promote
Antibiotic Stewardship, Surveillance
(cont’d)
3. Antibiotic Stewardship
• Process to review Antibiotic Utilization,
Susceptibility and Availability
• Appropriate antibiotic selection
• Indications for Use Documented
• 72 hour review
c. Prevent MDROs and Promote
Antibiotic Stewardship, Surveillance
(cont’d)
•
•
•
•
•
Timely IV to oral switch
Resistance Pattern Notification
Colonized or Infected Patients on Admission and
HEALTHCARE PERSONNEL are Identified and
Isolated
List of Current Reportable Diseases
Reportable Diseases are Reported to local and
State Health Departments
d. Infection Control Training
• Job Specific IC Training on Hire and ANNUALLY
• Blood Born Pathogen Training as Appropriate
• Policies on Sharps Injuries and Exposures—patient
and staff
• Treatment and Prophylaxis following exposure
• TB Conversion Follow-up
d. Infection Control Training
(cont’d)
• Respiratory Protection System
(N95 disposable respirator system)
• Annual fit testing
• Employee health policies:
• Reporting of illness without penalty
• Staff education regarding prompt reporting of
illness
d. Infection Control Training
(cont’d)
• Annual calculation of TB conversion rates
• Staff annual (at a minimum) IC training and
competency validation.
• Corrective action analysis following employee
exposures
d. Infection Control Training
(cont’d)
• Hep B Vaccinations Offered
• TB Testing Done Upon Hire (two step process)
& follow-up based on the facility risk
classification
• Annual Flu Immunizations Offered to all Staff.
2. General Infection Control Elements
• Applicable in all locations where patients are
treated
a. Hand Hygiene
b. Injection Practices and Sharps Safety
c. Personal Protective Equipment (PPE)
d. Environmental Services
a. Hand Hygiene
• Availability of hand-washing areas
• Availability of alcohol-based hand rub solution
• Hand hygiene is performed (even though gloves are
worn):
• before patient care
• prior to leaving a patient environment
• prior to an aseptic task
• following contact with blood, body fluids
or contaminated surfaces
a. Hand Hygiene (cont’d)
• Soap and water cleansing occurs when hands
are visibly soiled
• Artificial nails are prohibited in high risk areas
b. Injection Practices and Sharps
Safety
• Injection preparation areas
• Single use needles
• Syringes are used for only one patient, including
insulin pens
• Rubber stopper disinfection
• Medication vial access with a sterile needle ONLY
• Medication vial access with a sterile syringe ONLY
b. Injection Practices and Sharps
Safety (cont’d)
• Single Patient Use Items:
Single dose vials
IV bags
Medication tubing and connectors
•
•
•
•
Multidose vials are dated for 28-day expiration
Multidose vial use for multiple patients
Use of sharps containers for disposal
Sharps container replacement
c. Personal Protective Equipment
• PPE availability
• Staff glove when in contact with blood, body
fluids, mucous membranes or non-intact skin
• A glove change and hand hygiene prior to
moving from a contaminated to a clean body
site.
• Gown use
• Mouth, nose, and eye protection
• Surgical mask use
d. Environmental Services
•
•
•
•
•
Environmental service worker PPE use
Patient care area cleaning processes
Terminal Cleaning
Use of cleaners and disinfectants
Clean cloths for each patient room/corridor
d. Environmental Services (cont’d)
• Mop head and cloth cleaning daily
• Blood and body fluid cleaning process
• Equipment cleaning schedules (HVAC,
eyewash stations, ice machines, refrigerators,
scrub sinks and aerators on faucets)
d. Environmental Services (cont’d)
• Handling of clean and dirty laundry
• Bagging and storage of dirty linen
• Segregation of clean from dirty in laundry
processing area
d. Environmental Services (cont’d)
• Disinfection of non-critical reusable patient
care items, using manufacturers instructions if
applicable
• Cleaning of hydrotherapy equipment
3. Equipment Reprocessing
a. Reprocessing of Semi-Critical Equipment
b. Reprocessing of Critical Equipment
c. Single Use Devices
a. Processing of Semi-Critical
Equipment
•
•
•
•
•
High Level Disinfection Policy
Flexible endoscope inspection and testing
Pre-cleaning processes
Use of enzymatic cleaners
Cleaning brush maintenance
a. Processing of Semi-Critical
Equipment (cont’d)
• Chemicals used in high level disinfection
• Automated equipment processing
• Appropriate processing length of time and
temperature
• Rinsing process following disinfection
a. Processing of Semi-Critical
Equipment (cont’d)
• Drying of equipment following disinfection
• Maintenance records for disinfection
equipment
• Equipment storage following disinfection
• Logs regarding equipment use
b. Reprocessing of Critical Equipment
• Pre-cleaning process
• Use of enzymatic cleaners
• Cleaning brush maintenance
• Wrapping/packaging process
b. Reprocessing of Critical Equipment
(cont’d)
• Use of chemical indicators
• Use of biological indicators
• Bowie-Dick testing
gravity displacement vs pre-vacuum steam
sterilizers
• Labeling of sterile packs
b. Reprocessing of Critical Equipment
(cont’d)
• Sterilizer logs
• Maintenance of sterilizers
• Storage of sterilized items
b. Reprocessing of Critical Equipment
(cont’d)
• Inspection of processed items prior to use
• Flash sterilization
• Immediate use of flashed equipment
• Recall of sterilized equipment
c. Single-Use Devices
• Disposal after use or opening
OR
• FDA-registered vendors used for reprocessing
QUESTIONS?
Please submit questions to:
info@hfap.org