Infection Control Risk Assessment
2010
Overview
The 2010 Infection Control Risk Assessment has been completed reviewing potential threats to the hospital
related to acquiring and transmitting infections. This risk assessment is the first step in a systematic process to create and
implement an Infection Control Plan. In addition any Program Component that could be linked to Surgical Site Infections
(SSI), Central Line Bloodstream Infections (CLBSI), or Multi Drug Resistant Organisms (MDRO) were scored for that
individual infection.
Tool Design
The 2010 Risk Assessment tool was created using the 2009 Risk Assessment tool and updating it through a
brainstorming process with the Infection Control Nurse, Surveillance Nurse and an interdisciplinary group from the
hospital.
The tool has identified risk categories of
 Geographic
 Community
 Population
 Care
 Treatment
 Surveillance Activities; and
 Environment of Care
Each category has potential threats related to the acquisition and transmitting infections in the hospital. Each potential
threat was evaluated in 3 key areas: Probability / Actuality of Event, Severity of Risk, and Current Systems
/Preparedness. Additionally each program component will be assessed to see if it could have a direct impact on Surgical
Site Infections, Central line bloodstream infections or MDRO infections. If yes, each of these will be assessed for risk
individually.
The Probability / Actuality of Event Score was determined by evaluating the risk of potential threat actually
occurring. Information regarding historical data, environment of the surrounding area (airports, interstate, chemical
plants, railroad, etc.) and the scope of services provided by the hospital were considered when determining this score. In
evaluating the Severity of Risk in each potential threat if it actually occurred, the following issues were considered: loss
of limb / function, temporary loss of function, prolonged length of stay, moderate clinical / financial impact, and minimal
clinical / financial impact. The Current Systems / Preparedness score was determined by considering policies in place,
staff experience and response to actual situations, available services and equipment.
Process
The tool was created by the two infection control nurses. A blank Risk Assessment was then distributed to an
interdisciplinary group consisting of the Director of Pharmacy, Director of Critical Care Nursing, Maintenance
Supervisor, Microbiology Supervisor, Occupational Health Nurse Practitioner, Director of Operating Room, Director of
Housekeeping, Director of Quality, Vice President of Medical Affairs and the Infection Control Nurses.
The Surveillance Nurse asked each member of the Infection Control Team to submit an Infection Control Risk
Assessment. These were discussed with Infection Control Team at the October 26, 2009 meeting by the Infection Control
Nurse and their input was brought forward for the scoring process.
All members of the interdisciplinary group were invited to attend a meeting to score the tool. Before starting all
were asked to consider the following: (1) Have you noted any infection trends or patterns occurring in your department or
area this past year that should be closely monitored? (2) Have you noted any infection trends or patterns occurring in your
department or area this past year that should be closely monitored? (3) What is your department or area's number one
infection prevention and control priority? These were added to the tool and the tool was completed. Each participant had
the opportunity to add program components to the Risk Assessment before beginning. Some of the program components
were reworded and one was added. Based on the activities in the hospital and community some components were
removed as they were no longer applicable.
After the meeting the Risk Assessment and after input from members not able to attend the meeting the risk
assessment was typed and scores tallied. The Risk Assessment was redistributed to the group members as well as the
Chairman of the Infection Control Committee for review before the meeting. Changes and comments were solicited from
the group.
The Risk assessment was taken to the November 11, 2009 Infection Control Committee. The Committee
reviewed the Risk Assessment and made several changes. The Risk Assessment was approved.
Ranking of Scores
The scores could range from 0 (lowest vulnerability) to 11 (highest vulnerability). Additionally items were scored
against the risk of SSI, CLBSI or MDRO as per the Joint Commission National Patient Safety Goals. These were scored
using the same process and the general Risk Assessment.
Results
A potential threat scoring 8 or greater will be addressed in the 2010 Infection Control Priorities and
Goals. The following potential threats scored 8 or greater in the general Risk Assessment:
 Compliance with Isolation Policies and Prevention Practices
 Central Line Bloodstream infections
 Ventilator Associated Pneumonias
 Urinary Catheter Related Urinary Track Infections
 Surgical Site Infections
 Antimicrobial Resistant Organisms
 Compliance with Hand Hygiene
 Flash Sterilization
 Construction Activities
The following potential threats scored 8 or greater in the Risk Assessment related to Central Line Bloodstream
Infections
 Teaching Hospital
The following potential threats scored 8 or greater in the Risk Assessment related to Surgical Site Infections
 Teaching Hospital
 Flash Sterilization
 Construction Activities
The following potential threats scored 8 or greater in the Risk Assessment related to Multi Drug Resistant
Organisms
 Compliance with Isolation Policies and Prevention Practices
 Central Line related Bloodstream infections
 Ventilator Associated Pneumonia
 Compliance with Hand Hygiene
These Risks identified will be included in the 2010 Infection Control Plan.