Michele Barr, RN, BSN, CIC
Jennifer Perry, RN, BSN, CIC, CPHRM
Basic Infection Prevention Training

To visualize microbes the lab can stain them
using two common staining methods.
1. Gram stain
Gram + Purple
Gram – Red
Gram Stain – allows identification of four basic
groups of bacteria, and provide early
suggestion of empiric antibiotics to use and
possible initiation of isolation precautions.
2. Acid-fast stain


1.
2.
Acid-fast stain – The cells of some bacteria
and parasites are impervious to crystal
violet and other dyes, so heat or
detergents are used to force dye into this
type of cell.
If smear +, look closely at the patient to
determine if airborne isolation is needed.
S/S of TB?
Look at most recent chest x-ray.
•
•
•
•
•
Nutrient – type of plate
Optimal temperature - 35 – 37 degrees C.
Atmosphere – does the microbe need oxygen
or carbon dioxide?
Collection – (Do you have a specimen
collection policy? Check with lab, and
educate your people)
Tissue culture – Some viral pathogens are
more difficult to grow than bacteria, so non
culture methods are used for their
identification.
 MIC
studies help determine antimicrobial
susceptibility to antibiotics.
 The lowest concentration of an antimicrobial that
will inhibit the visible growth of a microorganism
after incubation.
(examples of disk diffusion)
Other methods to determine MIC are broth dilution, E-test, and automated systems.

1.
2.
3.
The zone sites are looked up on a
standardized chart to give a result of
Sensitive
Intermediate
Resistant
The charts have a corresponding column which
gives the minimum inhibitory
concentration for that drug.
(Example of E-test)
For instance this culture report – the Ampicillin zone of inhibition was >
32, according to the CLSI guidelines that the lab uses, that zone of
inhibition should be reported as “R”
 Done
annually by the Microbiology lab.
 Helps guide antibiotic usage, very specific to
the facility.
 See example in packet – let’s review!
•
•
•
In addition to traditional culturing methods,
there are non-culture methods to detect
microbes.
EIA (Enzyme immunoassay) This procedure
uses known specific antibodies which are
reacted with a patient specimen. If the
unknown patient antigen reacts with the
antibody, a visible result can be observed by
an enzymatic reaction. (i.e., Influenza A
virus antibody, HIV, Strep kit)
Advantage – rapid testing, agents that are
difficult to grow, very specific identification.
 Matches
DNA from an unknown agent, with
nucleic acid segments from a known agent.
 Lab
frequently uses this method for genital
specimens to detect Neisseria gonorrhea and
Chlamydia.
 PCR
enzymatically enhances the number of
nucleic acid molecules to the point that they can
be detected.
 Used
to detect Toxoplasmosis, Enteroviruses,
RSV, Pneumocystic carinii, and MTB.
 Disadvantage
– does not allow the testing of
antimicrobial susceptibility testing.
 PFGE
technique can be used with remarkable
precision to determine relatedness of isolates
from an outbreak…
•
•
•
“Can we culture the ice machine, I don’t
think they clean them, and I see some black
sludge on the dispenser”
Microbiological environmental testing is not
generally recommended. In most cases no
standards for comparison exist, so what are
you going to do with the information?
Just clean the ice machine and make sure
that there is a scheduled cleaning procedure.
Some are well adapted human pathogens, but most
are accidental pathogens that we acquire through
decaying organic matter or airborne spores.
•
1.
2.
Two groups
Yeasts – i.e. Candida species, Cryptococcus
Molds – i.e. Aspergillus species,
histoplasma capsulatum
What type of host plays an important part!
Construction on an oncology ward higher risk
than construction on a medical surgical
unit.

Cannot multiply on their own,
need living cells to live and grow

1.
2.
3.
4.
5.
Multiplication occurs in 5 steps
Attachment
Penetration
Replication
Maturation
Release
 Vary
in size and complexity, i.e. may be
single celled microscopic protozoa or
complex worms over 10 feet in length!
 Flukes,
tapeworms, roundworms, and
ectoparasites such as lice and scabies.
 Gram
positive cocci, easily grown in the
micro-lab.
 Normal flora on skin.
 Common pathogen – possesses numerous
invasive enzymes which aid its pathogenicity.
 Frequently resistant to the penicillin group of
antibiotics, including the oxacillin-like agents
(methicillin)





Commonly seen as “R” to Oxacillin on the culture report.
MRSA – cannot be taken lightly!
MRSA was first isolated in the United States in 1968. By the
early 1990s, MRSA accounted for 20%-25% of
Staphylococcus aureus isolates from hospitalized patients.
1999, MRSA accounted for >50% of S. aureus isolates from
patients in ICUs in the (NNIS) system.
in 2003, 59.5% of S. aureus isolates in NNIS ICUs were
MRSA.
•
•
•
•
•
•
Gram negative bacilli.
Most commonly associated with water.
Frequently a colonizing organism in patients.
“Opportunistic pathogen”, takes advantage
of lowered defense systems of the host.
Can be commonly resistant to multiple
antimicrobial agents.
Associated with outbreaks on healthcare
systems.
 Referred
to as an acid fast bacillus.
 Slow growing (can take 4-6 weeks to grow)
 Spread by the airborne route – so if + acid
fast smear +, consider negative airflow.
 If smear +, reportable to Oklahoma State
health department.
 Not
seen by gram staining – it is a virus.
 Requires tissue culture to grow.
 Can a Healthcare worker (HCW) with a
herpes lesion on their lip work?
 What if they work in the NICU or oncology?
 What if the HCW has a herpetic whitlow?
 How do you find the answers? (CDC
healthcare worker guidelines)
•
Colonization – presence of microorganisms
with multiplication but without tissue
invasion or damage. (urine culture E-coli <
20,000 cfu, patient with no symptoms)
•
Infection – entry and multiplication of an
infectious agent in the tissues of a host.
(urine culture E-coli >100,000 cfu, patient
has fever, frequency, dysuria)
 Exogenous
organisms are those that come
from outside the host.
 Endogenous
organisms are those that come
from the host’s own flora.
 Aerobic

needs oxygen, Containing oxygen; referring to an
organism, environment, or cellular process that
requires oxygen.
 Anaerobic

Lacking oxygen; referring to an organism,
environment, or cellular process that lacks
oxygen and may be poisoned by it.

ASEPSIS
Freedom from infection or infectious
material.
 BACTERIOSTATIC
Arresting the growth or multiplication of
bacteria. An antibiotic may be classified as a
bacteriostatic medication.
•
•
•
1.
Normal WBC count is 5,000 – 10,000
White blood cells originate in the bone
marrow.
Types of WBC
Phagocytic – ingest and destroy bacteria,
protozoa, cells and cellular debris.
(neutrophils, eosinophils, basophils, monocytes, and
macrophages)
2.
Non-phagocytic – important to immune
function and produce antibody. (T and B
lymphocytes)
 This
gentleman insisted his
students clean their hands
with a chlorine solution
between each patient. He
practiced in the 1800. Who is
he?
A. Oliver Wendell Holmes
B. Jack the Ripper
C. Ignaz Semmelweis
D. Joseph Lister
• The
most important
measure you can use to
prevent the spread the
spread of infection.
 When
washing hands with soap and water,
hands should be rub together vigorously for:
A. 6 seconds
B. 15 seconds
C. 20 seconds
D. 3 minutes
 When
hands are visibly dirty or contaminated
with proteinaceous material, hands should be
wash with:
A. Antimicrobial soap
B. Non-antimicrobial soap
C. A chlorine solution
D. Both A and B
 It
is not necessary to decontaminate your
hands if you are only touching intact skin.
A. True
B. False
 Soap
A.
B.
C.
D.
dispensers should be refilled:
When 2/3 full
When ¾ full
Never
Only when completely empty
 Natural
A.
B.
C.
D.
nail tip length should be:
Less than ¼ inch
Less than ½ inch
Bitten to nubs
Nails can be any length as long as they are
natural
 It
is not the responsibility of the facility to
provide lotion to the HCW, but the facility
should encourage the use of lotion to
minimize the occurrence of dermatitis.
A. True
B. False
 When
performing surgical hand antisepsis
one should:
A. Remove rings, watches and bracelets
before beginning the hand scrub
B. Leave all jewelry on during hand scrub so
you can clean the jewelry and hands at the
same time.
C. Remove only items that will be damaged by
the water.
Wash hands to prevent
transfer of microorganisms :
 Before
& after patient contact
 After gloves are removed
 Between task on the same patient to
prevent cross-contamination of different
body sites
 If
your hands have been exposed to Bacillus
anthracis, you should:
A. Wash your hands with antimicrobial soap
B. Wash your hands with non-antimicrobial
soap
C. Wash your hands with an iodophor
D. A and B
E. Cry
If visibly soiled, wash with soap, water and friction
 Who
collects the data at your facility?
 Audit tool (review sample tools)
 Calculation of Hand hygiene compliance
rates
 # of “yes” observations/Total # of
observations X 100
 Communicate
the data to the HCW’s.
% Compliant with hand hygiene
100
90
Monthly hand hygiene
rate
Facility Goal
80
70
60
50
Analysis – The April rate increased
To 92% from 82% due to increased
Hand hygiene awareness and
Discussion by administration at
Facility “Town Hall meeting”.
40
30
20
10
0
Jan-11
Feb-11
Mar-11
Apr-11
Action Plan – Continue hand hygiene
discussions by administration at
town hall meetings and
implement administrative hand
Hygiene rounds with IC dept. for increased
awareness.
Hand hygiene
matters!!!!!
Thank you Dr. ____
Infection prevention dept. loves it!
Thank you Dr. ______ 
Ideas to keep the ball rolling….
•
“Glow Germ” at staff meetings
•
Hand hygiene “huddles”
•
Hand hygiene videos to show at staff meetings,
orientation, advocate meetings, patient
videos.
•
Pictures of staff washing hands!
http://www.cdc.gov/handhygiene/Patient_materials.html
http://www.hhs.gov/ash/initiatives/hai/training/partneringtoheal.html
http://web.me.com/danielwlieu/Hands/Infection_Prevention_and_Cont
rol.html
Mandatory annual hand hygiene education
http://www.cdc.gov/handhygiene/training/int
eractiveeducation/
•
•
Small prizes or tickets for free food when
you catch a HCW performing hand hygiene.
(OFMQ – “thank you pocket card, be a life
saver pocket card”
•
Wear Hand hygiene apron when out on IC rounds, make
some for hospital managers.
•
iScrub - iScrub Lite is available free from the iTunes App
Store. Search for iScrub in the App Store
•
Face book/Twitter
•
Web page buttons –
Basic Infection Prevention Training
 Exposure
 Incubation
Period (time from exposure to
onset of symptoms)
 Onset
of symptoms/clinical disease
 Recovery,
disability or death
 Infectious
agent
 Reservoir
 Portal
of Exit
 Means of Transmission
 Portal of entry
 Susceptible Host
Apply
standard precautions to all:
 Patients
 Contaminated equipment, surfaces &
materials
Use
judgment to determine when
personal protective equipment is
necessary
Wear face mask with eye shield
or mask & eye protection during
patient care activities that may
generate splashes or sprays of
blood or body fluids
Prevent injury when using &
disposing of needles or other
contaminated sharp instruments
 Immediately dispose of used
sharps in puncture-resistant
container
 Do not recap using two-handed
technique


Keep work area clean

Minimize the splashing or
spraying of blood or body fluids while
performing procedures

Clean up spills of blood or body fluids
promptly using gloves & approved
disinfectant
Remove
gloves, gown, mask, eye
protection before leaving work
area
Gloves,
gown, mask are not worn
in halls, elevators, cafeteria, or
gift shop
Clean re-useable equipment
between patients to prevent
transfer of microorganisms to
other patients, staff
or environment
Use:
 Mouthpieces
 Resuscitation
bags
 Ventilatory device
As
an alternative to mouth-tomouth resuscitation methods
Patients infected or colonized with:
 Epidemiologically important
microorganisms
 Transmitted by direct contact with
the patient
 Indirect contact with room
surfaces or patient care items
Patient may have:
Incontinence
Diarrhea
Ileostomy
Colostomy
Wound drainage not contained
by dressings
 Wear
gloves and gown before entering room
 Change
gloves after contact with infective
material
 Remove
gloves before leaving room & wash
hands
 Avoid
contact with contaminated surfaces while
leaving room
Limit
transport to essential purposes
Communicate
precautions to
appropriate departments
Maintain
Contact Isolation
 Dedicate
non-critical equipment to Contact
Isolation patient
 Clean
& disinfect equipment between
patients to avoid spread of microorganisms
to other patients, staff, or environment.
 Upcoming slide – when should contact
isolation be discontinued????
Patients infected or colonized
with
Microorganisms
Transmitted
by droplet from
coughing, sneezing, talking, or
performing procedures
Wear
mask when working within three
feet of patient
Limit
transport to essential purposes
Minimize
dispersal of droplets by
masking patient if possible during
transport
Patients infected with:
Pulmonary
Rubeola
Varicella
tuberculosis (TB)
(measles)
(chicken pox)
Place
patient in a negative air-flow
isolation room
Keep
room
Limit
room doors closed & patient in
transport to essential purposes &
minimize dispersal of droplets by
masking patient
Tuberculosis
- wear particulate
respirator to enter room
Varicella
& Rubeola - susceptible
care givers not to enter room if
immune caregivers are available
 Susceptible
= mask
 Immune persons = no mask
 General
recommendations for all healthcare
settings independent of the prevalence of
multidrug resistant organism (MDRO)
infections or the population served.
 Administrative

measures
Make MDRO prevention and control an
organizational patient safety priority.
In healthcare organizations that outsource
microbiology laboratory services (e.g., ambulatory
care, home care, LTCFs, smaller acute care
hospitals), specify by contract that the laboratory
provide either facility-specific susceptibility data
or local or regional aggregate susceptibility data in
order to identify prevalent MDROs and trends in the
geographic area served.(363) Category II
 In
ambulatory settings, use Standard
Precautions for patients known to be

infected or colonized with target MDROs, making
sure that gloves and gowns are used for contact
with uncontrolled secretions, pressure ulcers,
draining wounds, stool incontinence, and ostomy
tubes and bags. Category II
 Discontinuation
of Contact Precautions. No
recommendation can be made regarding
when to discontinue Contact Precautions.
Unresolved issue
 Discussion
Intensified interventions to prevent MDRO
transmission.
List combinations of control elements that
were selected and have been shown to
reduced MDRO transmission rates in a
variety of healthcare settings.




Active surveillance cultures
Decolonization
 In
packet, it is an A-Z reference that details
what type of isolation is needed for specific
diseases and conditions.
 Scabies
 Lice
 Influenza
 C-diff
 TB
A
spore forming anaerobic gram positive
bacilli which are particularly virulent
because of the toxins they produce.
 On
April 11, 2005 at the annual meeting of
the Society for Healthcare Epidemiology of
America (SHEA) infectious disease experts
presented information concerning a new
highly toxic strain of C- Diff. (NAP 1 strain_

Hand Hygiene – soap, water, and friction.
Alcohol hand foam is not effective in killing
the spores of C – Diff. CDC states in outbreak
settings or settings with higher rates of cdiff, use hand washing only.
 Contact
Isolation – gloves and gowns when
entering the room of patient with c-diff.
The spores can be transmitted from person
to person, as well as by persons touching
objects (side rails, nurse call light)
contaminated with the spores.
 Use
of hypochlorite disinfectant (bleach) has
been found to be more effective in killing
the C-diff spores upon patient discharge.
 Educate
Health Care Workers
 Prudent
Antibiotic use.
 Infectious
disease caused by bacteria.
 Usually affects lungs.
 Other body parts can be affected.
 Spread
through air (droplet nuclei).
 Sneezing, coughing, speaking, singing by
individual with TB disease.
 Sharing the same air space with persons with
infectious TB disease.
 Weak
 Weight
loss
 Fever
 Night
sweats
 Cough
 Chest pain
 Coughing up blood
 Have
the organism
in their body.
 Have
 No
 Are
symptom.
 Bacteria
inactive.
is
symptoms.
sick.
 Bacteria
is active
and multiplying.
 One
or more drugs can no longer kill TB
bacteria.
 High risk persons for MDR TB:



Persons who did not take their TB meds.
Immunocompromised persons, i.e. cancer, HIV
infection.
Persons previously treated for TB with an
ineffective regimen of drugs.
 TB
drugs for TB disease.
 If
infected may need to take TB drugs to
prevent TB disease.
 TB
drugs are taken for 6-12 months.
 Discuss
Oklahoma Reportable Diseases
 Review PHIDDO system (open OSDH website
to review with the group)
 How do I get access to the system to report?
http://www.ok.gov/health/Disease,_Preventio
n,_Preparedness/Acute_Disease_Service/Dise
ase_Reporting/What_to_Report/index.html
Basic Infection Prevention Training
 Annual
Multi-disciplinary Risk Assessment –
done prior to your annual IC surveillance plan
review. Also review Example IC surveillance
plan.
 Construction
 TB
Risk Assessment (review form)
Risk assessment (review form)
 Multi-drug
resistant Risk Assessment (Annual
Antibiogram, historical date, data from SSI
organisms, C-diff lab ID event)
 Surveillance
1.
2.
3.
4.
Methods
Facility wide
Periodic (Quarterly)
Targeted (unit specific)
Outbreak Thresholds
 Collecting
Relevant Data
 Managing Data
 Analyzing and Interpreting Data
 Communicating Results
 Using




Definitions for data collection
Determine the population or event to study
Write your definition or use an established one
e.g. CDC NHSN
Apply the definition consistently
Write or find a data collection tool
 Concurrent
or retrospective data collection
 Review
your data collection for accuracy and
effectiveness



Check for flaws in the data
Check your data sources (patient based, lab
based, post discharge surveillance letters, post
op calls)
Validate if you make changes
 Record



data systematically
Be consistent (data collection tool)
Flow sheet or line list
Can others look at the data and understand it
 Think
about how you may want to
manipulate or analyze the data later


Computer system
Software for analysis (Excel)
 Analyzing

Analyze promptly to identify needs for
intervention
 Compare




Data
Same definitions
Same patient population, risk group
 Proper

is the reason we do surveillance
denominator
Device Days
Patient Days
Surgical Cases
 Compare



or Benchmark
Historically against your own rates
Against other hospitals of similar size
National Rates (Review NHSN report as a group)
 Interpretation



and Significance
Use of statistics
Data interpretation pit falls
Reporting Data





Statistics can summarize and simplify large
amounts of numerical data.
Using statistics one can draw conclusions about
data.
Statistics can help communicate findings clearly
and meaningfully to others.
Statistics can not prove anything- estimates are
normally presented in probabilistic terms (e.g.
we are 95% sure ...)
Statistics can not make bad data better "garbage in, garbage out"
 Statistics
may reveal underlying patterns in
data not normally observable.
 If
used correctly, statistics can separate the
probable from the possible
 Infection
Preventionists routinely use
statistical methods to:




Prepare reports for committee
Identify problems or outbreaks
Monitor the impact of interventions
Identify areas for improvement
 Some
commonly used statistical methods in
health care are:

Measure of central tendency




Mean
Median
Mode
Measures of Dispersion



Standard Deviation
Range
Variance

Measures of frequency




Incidence rate
Prevalence rate
Ratio
Proportion
 Statistical

process control
Control Charts
 What

is "Statistical Significance" (p-value)?
The statistical significance of a result is the
probability that the observed relationship or a
difference in a sample occurred by pure chance
("luck of the draw"), and that in the population
from which the sample was drawn, no such
relationship or differences exist. Using less
technical terms, we could say that the statistical
significance of a result tells us something about
the degree to which the result is "true" (in the
sense of being "representative of the
population").
 Typically,
in many sciences, results that yield
p .05 are considered borderline statistically
significant, but remember that this level of
significance still involves a pretty high
probability of error (5%). Results that are
significant at the p .01 level are commonly
considered statistically significant, and
p .005 or p .001 levels are often called
"highly" significant.
 This
is what adjusts for severity of illness.
Should be procedure-specific. (Review NHSN
SSI Data submission form)
 Based on 3 factors collected on all surgical
patients:



Length of surgery
American Society of Anesthesiology (ASA) Score
Surgical wound classification




What is a standardized infection ratio (SIR)?
The standardized infection ratio (SIR) is a summary measure used to
track HAIs at a national, state, or local level over time. The SIR
adjusts for the fact that each healthcare facility treats different
types of patients. For example, the experience with HAIs at a
hospital with a large burn unit (a location where patients are more at
risk of acquiring infections) cannot be directly compared to a facility
without a burn unit.
The method of calculating an SIR is similar to the method used to
calculate the Standardized Mortality Ratio (SMR), a summary statistic
widely used in public health to analyze mortality data. In HAI data
analysis, the SIR compares the actual number of HAIs in a facility or
state with the baseline U.S. experience (i.e., standard population),
adjusting for several risk factors that have been found to be most
associated with differences in infection rates.
In other words, an SIR significantly greater than 1.0 indicates that
more HAIs were observed than predicted, accounting for
differences in the types of patients followed; conversely, an SIR of
significantly less than 1.0 indicates that fewer HAIs were observed
than predicted.
Reference http://www.cdc.gov/hai/QA_stateSummary.html#
6
January – June, 2009
SIR = Observed (O) HAIs
Expected (predicted) (E) HAIs
To calculate O, sum the number of HAIs among
a reporting entity
To calculate E, requires the use of the
appropriate aggregate data from a standard
population (NHSN)
 Communicate/Report
 Look
Data
for trends (Analysis)
 Implement
 Monitor,
Changes (Action plan)
Track and report Effect of
Interventions
 How

Chart



to report
Pie Chart
Bar Charts
Graph


Line Graph
Control Chart
 Title
 Time
Period
 Location
 Values
 Unit Labels
 Definitions
•
Analysis:
–
•
No SSI
identified
since July
case
Action Plan:
Continue to do
surveillance
and discuss
prevention
measures
•
The Infection Preventionist has several roles
that are vital to the success of the program:
–
IP expert during surveys
•
•
•
•
•
Be familiar with survey process
Stay prepared
Keep up-to-date on survey hot topics
Know your policy and procedures
If you don’t know, DON’T make it up!!!
•
Collaborator with diverse departments
–
Maintenance
•
•
–
Housekeeping
•
•
•
–
ICRA
Water/Mold remediation
Cleanliness issues
Proper Chemical use and selection
In-services
Employee Health
•
•
Work Restrictions
Education on Communicable Diseases
 Infection
Prevention and control expert
 Mentor staff
 Role model for Infection Prevention and
Control
 Resource for the staff
 Design and implement effective programs
 Liaison
to public health
 Liaison in emergency preparedness
 Promote zero tolerance for HAIs
 Collect and analyze infection data
 Develop and review policies
 Consult on infection risk assessments,
prevention and control strategies
 Educate
and direct interventions to reduce
infection risk
 Implement change mandated by regulatory
bodies
 Evaluate Product changes
 Evaluate Chemical changes
 Development of IC Surveillance plan and
annual evaluation
 Read and interpret guidelines







Announcements that need to be recorded in the
minutes
News related to Infection Prevention
Updates from any construction projects
Reports from regular surveillance
Reports from Employee Health
Reports from Dialysis water cultures
Reports from IC Rounding
 One
of the most important activities for an IP
is Rounding. Through rounding the IP:





Develops relationships with staff
Identifies educational opportunities
Identifies breaches in practice
Identifies cleaning and disinfection issues
Identifies opportunities for improvement
 Review
rounding tool(s)
 Join

Dues $25 annually
 Text



EPIC
books
APIC Manual
Control of Communicable Diseases Manual
The Pink Book
 Websites
Basic Infection Prevention Training
 Employee
and/or worker Health
examinations chapter 667-5-4

Pre employment exams for







Each employee full or part-time with or without
patient care responsibilities
Physicians
Emergency medical personnel
Students
Lab and pharmacy workers
Volunteers and administrative staff
Food service workers
The pre employment health exam will include but not be
limited to:
Immunization History



Born before 1957
Born in 1957 or later
Serologic screening
Tb Skin Testing
2-step Testing
BCG
Hepatitis B

(e) Annual influenza vaccination program. Each hospital shall have an annual influenza
vaccination program consistent with the recommendations of the Centers for Disease Control and
Prevention Advisory Committee on Immunization Practices that shall include at least the following:

(1) The offer of influenza vaccination onsite, at no charge to all employees and/or workers in the
hospital or acceptance of documented

evidence of current season vaccination from another vaccine source or hospital;

(2) Documentation of vaccination for each employee and/or worker or a signed declination
statement on record from each individual who

refuses the influenza vaccination for other than medical contraindications; and

(3) Education of all employees and/or workers about the following:

(A) Influenza vaccination;

(B) Non-vaccine influenza control measures; and

(C) The symptoms, transmission, and potential impact of influenza.

(4) Each hospital influenza vaccination program shall conduct an annual evaluation of the program
including the reasons for nonparticipation.

(5) The requirements to complete vaccinations or declination statements for each employee and/or
worker may be suspended by the

hospital's medical staff executive in the event of a shortage of vaccine as recognized by the
Commissioner of Health.
 TB

Skin Test
Based on annual TB risk assessment
 Communicable
Diseases
A
file shall be maintained for each employee
containing the results of the evaluations and
examinations and the dates of illness related
to employment.
 These
are for Credentialed non-employees
(physicians/mid-level providers)

Such workers provide evidence of immunization
history and TB skin test consistent with the TB
Control Program. It is in the form of a signed
attestation statement.
 667-13-1



Infection Control Program
Provide a sanitary environment
Avoid sources and transmission of infection
Provide written policies and procedures for:



identifying, reporting, evaluating, and maintaining
records of infection among patients and personnel.
Ongoing review and evaluation of all aseptic, isolation
and sanitation techniques employed in the hospital
Development and coordination of training programs in
infection control for all hospital personnel.
 667-13-2


Infection Control Committee
Shall meet at least quarterly
Attendees – at least one person with appropriate
background who can speak for the relevant
department(s) attends the meeting or is
consulted.
 667-13-3


Policies and Procedures
The infection control committee shall evaluate,
revise, and approve the type and scope of
surveillance activities at least annually
Policies and Procedures shall be reviewed
periodically and revised as necessary
 667-13-4






Policy and Procedure content
Record of all reported infections generated by
surveillance activities
Handling and disposal of biomedical waste
Related to admixture and drug reconstitution
Indications for and type of isolation for each
specific disease
A definition for nosocomial infection
Designation of an Infection Control officer


A program of orientation of new employees and
other workers including physicians
A program of continuing education concerning
infection control
 482.42



Infection Control
Provide Sanitary environment to avoid sources
and transmissions of infections and
communicable diseases.
Must have active program for the prevention and
control and investigation of infections and
diseases.
A person or persons must be designated as the
Infection Control officer
•
•
•
Log of incidents related to infections and
communicable diseases (review sample log)
The CEO, medical staff and director of
nursing MUST ensure that there are hospital
programs and training related to infection
control and they are responsible for the
implementation of successful corrective
action in problem areas
Review the 16 page CMS IC surveyor audit
tool.
CMS Mandatory Reporting
 Requires
Bloodborne Pathogens Exposure
Control Plan that must include the following:




Purpose
Scope
Definitions
Exposure determination

Control Measures








Engineering Controls
Work Practice Controls
PPE (personal protective equipment)
Hepatitis B vaccination
Post exposure evaluation and follow-up
Sharps Injury log
Training and Education
Recordkeeping




Bloodborne pathogens 1910.1030 29CFR
www.osha.gov/pls/oshaweb/owadisp.show_document?p_ta
ble=STANDARDS&p_id=10051
1910.1030(c)(1)(iv)(B) Document annually consideration
and implementation of appropriate commercially available
and effective safer medical devices designed to eliminate
or minimize occupational exposure.
1910.1030(c)(1)(v) An employer, who is required to
establish an Exposure Control Plan shall solicit input from
non-managerial employees responsible for direct patient
care who are potentially exposed to injuries from
contaminated sharps in the identification, evaluation, and
selection of effective engineering and work practice
controls and shall document the solicitation in the
Exposure Control Plan.
•
•
•
TB Control plan and Risk Assessment
http://www.cdc.gov/tb/pubs/mmwr/Maj_gu
ide/Control_Elim.htm
Risk Assessment Appendix B must be done
annually.
–
–
–
•
Low
Medium
High
Contact Investigation
Intermediate Infection Prevention Training
Collaboration = key to success!!!
 Use
an audit tool to document the rounds.
 How often should rounds be done?
 Who should do the rounds?
 Communicate the findings found during OR
rounds.
 Learn from OR co-workers!!! Thank them 
 Consider implementing an “OR best
practices” campaign, using AORN standards
and recommended practices.

Ensure that the patient gets appropriate pre-op
antibiotic within an hour of “cut time.”

Keep patients warm, must be ≥ 96⁰ F

Apply skin prep according to manufacturer
instructions, allow to dry before draping.

Hand hygiene before and after patient care.

Limit “traffic” in and out of room during surgical
procedures.
 Be
sure that the central line “insertion
bundle” is used when central lines are
placed. (Evidence based practice)
1.
2.
3.
4.
5.

Hand hygiene prior to line insertion
Use Chlorhexadine skin prep and allow to dry.
Avoid the femoral site (it is associated with more bacteria)
Those inserting the line and any personnel assisting must wear
sterile hat, mask, gown and large drape used to cover the
patient during placement.
Assess the line every shift to ensure it is still needed, if not get
an order to remove.
Use alcohol to “scrub the hub” before
accessing the line for medications or
blood draws.
 2011
AORN recommended practices for
preoperative patient skin antisepsis, pages
361-377.
 Pre-op shower? What are your facilities
policies? Is there a place to document?
 Pre-op antibiotic given by anesthesia
personnel within 60 minutes prior to incision
 What are your SCIP #’s on this measure?
 How often are the surgery staff and
physicians informed of their SCIP data?
 OR
appears clean – 2011 AORN recommended
practices “Environmental cleaning”, pages
237-249.
 OR facility in good repair
 Sub-sterile area appears clean
 Scrub sink area appears clean
 Interim (between cases) cleaning performed
 Terminal cleaning
 Ventilation
requirements: 2011 AORN
recommended practices, “Safe environment
of care”, pages 218 – 220.
 Positive pressure how often is this checked?
 Doors closed during the case?
 Temperature between 68 and 73 degrees F
 Humidity monitored?
 ACH monitored? (OR, PACU, Sterile storage)
During rounds, how are you seeing hands being
cleaned before and after patient care?
1. Soap and water?
2. Is an alcohol product used if hands are not
visibly dirty?
3. Who collects hand hygiene data for your
surgical area?
4. How often are the results communicated?
5. Hand lotion, what is the staff using?
It is all about the hands!!!!!
Keep them healthy
1.
2.
3.
4.
Short natural nails
Remove fingernail polish if chipped
Use hospital approved lotion
Use soap water and friction for at least 15
seconds when washing
 Is
the traditional surgical hand scrub being
used?
 If so, how long is the scrub? 3 or 5 minutes?
 If your facility has moved to an alcohol based
antiseptic surgical hand rub, are they
following the manufacturers instructions for
use?
 Consider annual competency…

Apply to clean dry hands, use nail pick to clean under nails with
first hand wash of the day.
Pump # 1
Dispense one pump (2 ml) into the palm of one hand. Dip fingertips of the
opposite hand into the hand prep and work under fingernails. Spread
remaining hand prep over the hand and up to just above the elbow.
Pump # 2
Dispense one pump (2 ml) and repeat procedure with opposite hand.
Pump # 3
Dispense final pump (2 ml) of hand prep into either hand and reapply to
all aspects of both hands up to the wrists.
Allow to dry. Do not use towels!
Applying correctly matters.
 2011
AORN recommended practices, “Hand
Hygiene”, pages 73-85.
 Artificial nails should not be worn by
healthcare personnel in the operative
environment, any fingernail enhancement or
resin bonding product is considered artificial.
 Rings
 Watches and bracelets

Remind co-workers and physicians of following
opportunities for hand hygiene!!!!
Decontaminate hands after –

Contact with a patient’s intact skin (e.g., when
taking a pulse or blood pressure, and lifting a
patient)

If moving from a contaminated-body site to a
clean-body site during patient care.

After contact with inanimate objects (including
medical equipment) in the immediate vicinity of
the patient.






Sterile items left open no > than 30 minutes prior to
patient entering room
Scrubbed persons maintain sterility of sterile gown,
gloves, supplies
Hands remain above waist
Sterile field constantly monitored
Items introduced into sterile field opened, dispensed,
transferred by methods to maintain sterility/integrity
Items/devices dropped below level of the OR table
are considered contaminated
 All
personnel moving in/around sterile field
do so in manner to maintain sterility
 Adjacent sterile fields not at disparate
heights
 Separation of sterile team from non-sterile
team maintained
 Staff do not turn back to sterile field
 Traffic in and out of room kept to minimum
Safe injection practices used for IV tubing,
fluids, medication vials?
 CMS surveyor tool – “Injection Practices”
 “Observations are to be made of staff who
prepare and administer medications and
perform injections (e.g., anesthesiologists,
certified registered nurse anesthetists,
nurses).”
 Link to the 16 page surveyor tool 
http://totalsol.vo.llnwd.net/o29/data/1080/infectio
n_control_surveyor_worksheet.pdf
 Aseptic
practice used for all invasive
procedures: (epidurals, blocks, IV insertion)
 Anesthesia cart appears clean, who cleans
after each case?
 Cleans shared equipment (e.g., stethoscope)
between cases

Keep patients warm during surgery – the
recommendation is to keep patients ≥ 36.0 C
(96.8 F) Remind anesthesia to monitor during
surgery.

Date all multi-dose vials when you open, they
are only good for 28 days after opening and
maybe sooner if manufacturer recommends…







Appropriate eye protection used
Sharps containers not overfull
Shoe covers/boots if indicated
Surgeons/first assistants double gloved
(recommended)
Circulators wear gloves for handling contaminated
items. Performs hand hygiene after glove removal
Sharps are passed in a basin or by using neutral zone
rather than by hand
Sharps safety devices
A
fresh surgical mask should be worn for
every procedure. Literature shows that after
4 hours surgical masks had decreased
efficacy.
 Surgical masks should be discarded after
each procedure.
 Surgical masks should not be worn hanging
down from the neck.
(AORN 2011 perioperative standards and recommendations)
Patients with communicable disease handled
appropriately
 Sterile team removes gloves and performs hand
hygiene at end of case
 Policies regarding “Immediate Use Sterilization”
are followed
 Personnel appear free from communicable disease
(no open skin lesions on hands/face)
 Observers comply with “Observers Protocol” for
Surgical Services
 Surgical attire (AORN, CDC, SHEA)
 Clean, sterile, and soiled items are kept separate
 Instruments are kept moist during cases.

1.
2.
Wipe instruments as needed with sterile surgical
sponges moistened with sterile saline during the
procedure to remove gross soil.
Instruments with lumens should be irrigated with
sterile water as needed through the surgical
procedure.
2011 AORN Standards and
recommended practice, “Care of
instruments”, pg 431
Yes!!!!!
And there are audit tools for that too….
http://www.infectionpreventiontools.com/
http://www.ofmq.com/hai
http://www.ascquality.org/Library/sterilizationhighleveldisinfe
ctiontoolkit/Sterilization%20Audit%20Checklist%20SPSmedical
.pdf
http://www.ascquality.org/SterilizationHighLevelDisinfectionTo
olkit.cfm
www.cipconsultingllc.com