Healthcare-Associated Infections, Identifying
Highlights
Policy Statement
The facility shall attempt to identify and distinguish healthcare-associated infections from
those acquired in the community.
Policy Interpretation and Implementation
Definitions
1.
Healthcare-associated infections (HAIs) are those that are acquired during the
delivery of healthcare across settings (hospitals, home health, in the facility), in
contrast to those that were acquired prior to entering the healthcare setting but may
persist after admission to the facility.
Goals of Determining HAIs
2.
The goals of determining healthcare-associated infections are:
a. To identify and correct breaches in infection control practices that may have
contributed to the spread of a healthcare associated infection;
b. To prevent the further spread of infection (resident-to-resident, staff-to
resident) through the initiation of appropriate isolation precautions where
warranted;
c. To identify and treat epidemiologically important organisms (e.g., C. difficile,
MDROs) that have a high risk of transmission, severity of disease, and/or are
difficult to treat.
Review of Data
3.
When an infection is identified, the Infection Preventionist, with the input of the
nursing staff and Attending Physician as needed, will confirm that the situation
meets the criteria for an infection and will attempt to identify whether the infection
developed in the facility. This will be based upon standard, published definitions of
infections, laboratory results, and surveillance data collected in the facility.
Reporting Data to the IC
Committee or QA&A
Committee
4.
The Infection Preventionist will report surveillance information to the Infection
Control Committee and the Quality Assessment and Assurance Committee
performing infection control oversight functions. The committee will review the
reports and identify trends, patterns, or problems that might reflect the
development of healthcare-associated infections.
Surveillance Forms and
Procedures
5.
The facility has established procedures and forms to perform and document
surveillance.
References
OBRA Regulatory
Reference Numbers
Survey Tag Numbers
Related Documents
Policy
Revised
483.65(a)
F441
Surveillance for Infections
Infection Report Form (CP1817) (Appendix A)
SHEA/CDC Position Paper: Surveillance Definitions of Infections in Long-Term Care
Facilities: Revisiting the McGeer Criteria (Appendix A)
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© 2001 MED-PASS, Inc. (Revised April 2013)