Infection Control Plan 2012
Purpose
The risk of development of a healthcare-associated infection (HAI) is minimized through a hospital-wide infection control
program. The purpose of the infection control program at Cabell Huntington Hospital is to influence, support and
improve the quality of healthcare through the practice and management of infection prevention/control and the application
of epidemiology in health settings. The mission of the CHH infection control program is to improve health and patient
safety by reducing risks of infection and other adverse outcomes. The primary goal of the organization-wide infection
control program is to identify, prevent, and reduce risks of endemic and epidemic healthcare-associated infection in
patients, employees, physicians and other licensed independent practitioners, contract service workers, volunteers,
students and visitors and to ensure optimal operation of the health care facility by
 Preventing Infections
 Identify organisms of epidemiological importance coming into the hospital
 Intervening directly to interrupt the transmission of infectious diseases; and
 Educating and training healthcare workers and providers.
Infection Control Scope of Services/ Processes/Structure
The mission of Cabell Huntington Hospital (CHH), Huntington, WV, is to meet the lifetime health care needs of our
community; to provide an atmosphere of service, quality, and efficiency; and to maintain an emphasis on health care
education. The vision of CHH is to be the hospital of choice for all ages in the communities we serve. CHH is affiliated
with Marshall University School of Medicine, CHHI Foundation, and Tri-State MRI. The hospital has 313 licensed beds
and services a population market size of approximately 323,145. CHH serves as referral center for our tri-state region.
Patient population served includes the following medical specialties: Family Practice, Internal Medicine, Oncology,
Pulmonary, Cardiology, Pediatrics, Obstetrics & Gynecology, Urology, Nephrology, Orthopedics, Neurosurgery,
Surgery, Endoscopy, Ophthalmology, and Invitro Fertilization. Services provided include a Level II Trauma Center,
Mother/Baby Unit, Level III Neonatal Intensive Care Unit, a Pediatric Intensive Care Unit, Burn Intensive Care Unit, an
outpatient Comprehensive Cancer Center for pediatric and adults and five physician office practices. Also offered:
bariatrics, wound care to include a hyperbaric chamber, joint replacement, robotic procedures, cosmetic surgery, senior
services, pain rehabilitation programs, cardiac and pulmonary rehabilitation, neuroscience, inpatient and inpatient
dialysis. CHH is a not for profit academic community hospital. This population consists of a high number of individuals
with many underlying disease processes that put them at high risk for infection.
The hospital has identified infection preventionists as individuals with clinical authority over the infection prevention and
control program. The Infection Control Program includes two infection preventionists. Both are registered nurses; one is
master’s prepared with documented training in infection control practices and is certified in infection control. The second
registered nurse is newly hired and working towards a master’s in nursing informatics and certification in infection
control. The infection control function reports to the Director of Quality and Performance Improvement who reports to
the Vice-President of Medical Affairs. Responsibilities of the infection preventionists include, but are not limited to:
 Managing the Infection Control Program under the direction of the Chairperson of the Infection Control
Committee
 Collecting and coordinating data collection, tabulation and reporting of healthcare-associated and
communicable infections
 Facilitating the ongoing monitoring of the effectiveness of prevention/control activities and interventions
 Educating selected patients, families and hospital staff about infection prevention and control principles
 Serving as a consultant to patients, employees, physicians and other licensed independent practitioners,
contract service workers, volunteers, students, visitors and community agencies
 Taking action on recommendations of the Infection Control Committee
 Rounding in clinical areas
Infection Control Plan 2012
The Infection Control Committee is sanctioned by the Medical Executive Committee and is a multidisciplinary team. The
Chairperson of the Infection Control Committee is a physician with special education and experience in infection control
practices. In addition to chairing the Committee, the Chairperson works collaboratively with the infection preventionists
for administration and management of the infection control program. The committee membership participates in the
development of strategies for components/functions of the Infection Control Program and includes representation from
the Medical Staff, Administration, Nursing Service, Safety, Physician Office Practices, Laboratory, Performance
Improvement, Housekeeping, Operating Room, Pharmacy and Community Health. Determining the effectiveness of the
key processes for preventing and controlling infections is an ongoing function of the Committee. Infection Control
Committee meeting minutes are routed to the Medical Executive Committee to include assessing the adequacy of
resources allocated to support infection prevention and control activities. IC.01.01.01 EP 1-3
Strategies for Reducing Infections
CDC Standard Precautions are implemented to prevent infection transmission of infections.
http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html. Standard Precautions apply to blood, body fluids,
secretions, and excretions except sweat, regardless of whether or not they contain visible blood; nonintact skin, and
mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both
recognized and unrecognized sources of infection in hospitals. An Infection Control Program Risk Assessment is
completed annually and approved by the Infection Control Committee. Infection control is represented on the following
committees: Products Evaluation Committee, Patient Education Committee, Joint Commission Survey Preparedness,
Quality Champions, Critical Care Committee, Environment of Care, and Nurse Management Meeting thus providing a voice
for reducing infections and is linked to the infection control program’s mission to protect the patient, protect the health care
worker, and perform this mission in a cost-effective manner. IC.01.05.01 EP 2
Surveillance definitions are from the following sources:
Horan, TC, Andrus, M, and Dudeck, NA.CDC/NHSN surveillance definition of health-care associated infection and
criteria for specific types of infections in acute care setting. In: American Journal of Infection Control 2008; 36 (5):
309-332.
The surveillance plan is based on the following:
 Demographics of CHH
 Populations served
 Hospital services provided
 Previous surveillance data
 Identified high volume, high risk and problem prone procedures
 Current scientific research, and
 Joint Commission Standards, Centers for Medicare Services (CMS) and other regulatory agencies
 WV State Law and
 Resources available
The surveillance methods performed by the infection control nurses are comprehensive, prospective, and retrospective.
The infection control program is linked with microbiology and other data sources. The infection control nurses screen all
positive microbiology reports, including those from off-site facilities. Screening results determine whether culture reports
warrant further investigation, monitoring, reporting contagious diseases to appropriate health departments, notifying
transferring facilities of significant organisms and/or discarding due to nonsignificant findings. Device related infection
rates are reported monthly according to CDC National Healthcare Safety Network (NHSN) Guidelines. Infection control
reports are disseminated to appropriate departments for use in performance improvement activities. Performance
improvement surveillance monitors are chosen to reflect how the hospital can improve the quality of healthcare through
the practice and management of infection control and the application of epidemiology in health settings. These
surveillance activities reflect the infection control program’s mission.
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Infection Control Plan 2012
Risks Assessment Process
The Infection Control (IC) Risk Tool is used to define areas of risk based on: geographic location, community,
population, care, treatment, services, surveillance activities, and environment of care. The Risk Assessment is conducted
annually and priorities identified. New risks or priorities are identified through surveillance monitoring and review of
performance improvement indicators. IC.01.03.01 EP 1-3 Added in 2010 were Joint Commission National Patient Safety
Goal indicators. The tool was revised to specifically capture the risk of acquiring or transmitting central line bloodstream
infections, multi drug resistant organisms and surgical site infections, NPSG.07.01.03, 07.01.04, 07.01.05.
Priorities that are based on Review of Joint Commission Standards, CMS Conditions of Participation, and
applicable State and Federal Laws and include the following surveillance monitors:
1. Healthcare Associated Infections in Special Care Units
2. Central Line Bloodstream Infections Housewide
3. Occurrence of Healthcare Associated Infections that Significantly Exceed the Usual Baseline Levels
(Epidemiologically important)
4. Communicable/Reportable Diseases to Public Health Authorities
5. Infections of Epidemiological Significance Among Employees
6. Sterilizer Spore Test Results
7. Pharmacy Hood Test Results
8. Reverse Osmosis Dialysis Water Bacteriologic Testing Results
9. Safety/Environmental and Construction Rounds
10. Increase in Influenza-Like Illness, Rash with Fever, Gastroenteritis, Acute Asthma Attack, Sepsis/Septic Shock in
ED Patients and CHH Employees (Bioterrorism Syndrome Surveillance)
11. Health Care Acquired Infections Contributing to Death
12. Hand Hygiene Compliance
13. Tuberculosis Control Program Risk Assessment
14. Compliance with prevention practices related to central line associated bloodstream infections, multi drug resistant
organisms, and surgical site infections.
Selected departmental performance improvement indicators are:
1. Occupational Health: Employee Blood/Body Fluid Exposures
2. Critical Care Ventilator Associated Pneumonia
3. Infection Control: Multidrug Resistant Organisms Prevention Processes
4. Occupational Health: Influenza Program
5. Surgical Services: Selected in and Outpatient Surgical Site Infections
6. Epidemiologically Important & Multidrug Resistant Organisms
Outbreak Investigation
See “Nosocomial Outbreak Investigation Guidelines,” Infection Control Manual, Section I, Policy 6. IC.01.05.01 EP 5
Integration of Hospital Components and Functions into Infection, Prevention and Control Activities
Infection control is integrated into clinical departments. Clinical departments complete the “Guidelines for Infection
Control Policies” template, which identifies department specific infection control concerns. From the concerns,
department specific infection control policies are developed. Each department’s “Guidelines for Infection Control
Policies” and department specific infection control policies are reviewed/revised every 2 years. The department manager
or designee and infection preventionist discuss propose revisions before submitting to infection control committee for
final approval. After final approval, the infection preventionist communicates decisions made to the department manager.
Major policy revisions or changes are also discussed at the infection control committee before implementation. See
attached calendar listing departments and review dates. IC.01.05.01 EP 6
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Infection Control Plan 2012
Communication
The hospital communicates responsibilities about preventing and controlling infections is communicated through the
following processes.
Internal Communication IC.01.05.01 EP 7
Licensed independent practitioners
 Medical Section Committee meetings
 Balanced Score Card data
 Outcome data related to NPSG 7
 Focused education related to community or hospital event related to infection control
Staff:
 General New Employee Orientation, Nursing Orientation, PCA Orientation, Resident Orientation, annual
ongoing education, and in-services as requested by staff
 The infection preventionist attends the following committees and meetings: Products Evaluation Committee,
Patient Education Committee, Joint Commission Survey Preparedness, Infection Control Team, Hand Hygiene
Team, Critical Care Committee, Environment of Care, Quality Champions, Nursing Leadership Meeting, and
weekly medical affairs department meeting.
 Balanced Score Data
 Outcome data related to NPSG 7
 Focused education related to community or hospital event related to infection control
Visitors, Patients and Families
 WHO “My Five Moments for Hand Hygiene” sign on sharps containers
 Respiratory Etiquette sign posted during respiratory viral season

“How to Prevent Staph Infections” posted in elevators and in departments
 Infection control/disease specific patient education handouts
 Focused education related to community or hospital event related to infection control
External Communication
The hospital communicates information to external organizations re: infection surveillance and control issues.
Communicable diseases are reported to health departments. Positive test results indicating infections from sending and
receiving health care facilities are reported. IC.01.05.01 EP 8
Other Duties of the Infection Preventionist
1. Education
The infection control program aims to educate and train health care workers and providers. An annual educational program
is provided to all departments. New employee education is performed monthly to cover the following topics: impact of
healthcare acquired infections, NPSG 7 requirements, hand hygiene, surveillance, prevention and control of infectious
diseases, CHH isolation system, tuberculosis, managing infectious wastes, engineering and work practices to prevent
occupational exposure, policies for cleaning blood/body fluid spills, etc. Numerous infection control educational
programs are presented upon request to various departments according to voiced need.
2. Consultation
The infection preventionist is available to all departments, medical and dental staff. The infection control program works
with the infection control committee to identify, prevent, and reduce risks of endemic and epidemic nosocomial infection in
patients, employees, physicians, contract service workers, volunteers, students and visitors and ensure optimal operation of
the health care facility by
 Managing infections
 Recommending policies and procedures
 Intervening directly to interrupt the transmission of infectious diseases.
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Infection Control Plan 2012
3. Environmental Issues
Construction rounds are completed weekly; environmental rounds completed twice monthly to include in-hospital as well
as off-site facilities. The infection preventionist is involved in construction planning and monitoring. An infection
control risk assessment is completed for each construction project. Employee health and infection control concerns and
issues are reported to the Environment of Care and Infection Control Committees.
4. Occupational Health
Infection control works closely with employee health to accomplish required services. Employee Health and Infection
Control collaborate in developing, reviewing and revising policies such as Management of Health Care Workers with
Blood and Body Fluid Exposures. Work restrictions policies are based on
 CDC, Guidelines for Infection Control in Dental Health Care Settings - 2003. MMWR, December 19,
2003/52(RR17); 1-61.
 Adapted from Bolyard EA, Hospital Infection Control Practices Advisory Committee Guidelines for infection
control in health care personnel, 1998. Am J Infect Control 1998:26:289-354.
 Recommendation of the Advisory Committee on Immunization Practices (ACIP).
Employee Health and Infection Control collaborate in developing, reviewing and revising the Occupational Health TB
Program. The Program delineates TB screening, prevention, and work removal program for CHH employees
and independent contractors. All employees receive baseline TB screening upon hire using a 2-step tuberculin
skin test (TST) or a single blood assay for M. tuberculosis (BAMT) to test for TB infection. Frequency of
employee TB screening is based on the annual risk classification. In the event of health care worker exposure to
a patient with a diagnosis of active tuberculosis, Employee Health and Infection Control departments complete
follow-up. TB skin test screening is done. For additional information, review the following employee health
policies, "Tuberculosis Skin Testing Program," and "Management of Health Care Workers with Contagious
Disease Exposure."
5. Home Health
Definitions of home-care acquired infection for surveillance rely more on clinical signs and symptoms and tests that can
be performed by the home-care nurse at the bedside. Infection prevention practices in the home include hand washing,
home infusion therapy, respiratory care, wound care, urinary tract care, and isolation precautions. The infection
preventionist regularly reviews positive culture reports with the home health director. Assessment of home health
policies to include cleaning and reprocessing of equipment, surveillance, implications for occupational health, and
program design are reviewed every 2 years. The infection preventionist accompanies the home health nurse annually on a
home visit.
Emergency Preparedness and Management
Infection preventionists participate in the hospital wide emergency plan via the Hospital Incident Command System
(HICS). In the HICS system Biological / Infectious Disease Medical Specialist will be called in as needed by the Incident
Commander.
In the event of an influx of potentially infectious patients there are multiple established resources for use. The hospital is
part of West Virginia Region II Emergency Response System who has an Emergency Manual for all the hospitals in the
region listing resources regarding infectious patients, including bioterrorism. This manual is updated every other year.
The Infection Control Department works collaboratively with the local and state heath departments that serve as
resources. The hospital has full Internet capabilities and access to a full service library. IC.01.06.01 EP1
The infection control department receives updates from the local and state health departments regularly regarding
emerging infections in the community and state, as well as surge capacity and syndrome surveillance. Syndrome
surveillance reports include Emergency department and Employee Health statistics and are reported to Infection Control
weekly. The syndromes monitored are asthma, diarrhea, gastroenteritis, vomiting, fever, rash, sepsis / septic shock, and
chicken pox. This data is trended weekly and reported monthly. IC.01.06.01 EP2
In the event that patterns are identified the hospital communicates this information to licensed independent practitioners
and staff. The Vice President of Medical Affairs would be notified and would communicate the information to the
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Infection Control Plan 2012
medical staff via the medical staff structure. The nursing staff also has a similar structure and the Vice President / Chief
Nursing Officer would be notified and information communicated to Nursing Directors, Unit Mangers and Assistant
Directors of Nursing for communication to staff. The hospital has an education department that can be of assistance if
needed in staff education. IC.01.06.01 EP3
The hospital has developed a Contagious Patient Plan / Code Green that details the hospitals planned response to an
influx of infectious patients. The Plan addresses infectious control practices for patients, post exposure management,
management of large scale exposures, post incident debriefing, laboratory support and CDC information if needed.
IC.01.06.01 EP5 If needed the hospital has a nurse-staffing plan that can be implemented to care for patients over an
extended period of time. IC.01.06.01 EP5
Annual Evaluation of Plan
The Infection Control Progress Report is updated/reviewed quarterly at infection control committee meetings. New risks
or changes in priorities are identified throughout the year. At the end of each year outcomes of each identified goal is
determined and considered for inclusion in next year’s plan. The revised Plan is taken to the infection control committee
for final revisions and approval. IC.01.05.01 EP 3
Approved by the Infection Control Committee 01/12/2011
Revised 03/09/11, 12/11
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